New Patient Form
Patient Information
First Name:
Last Name:
Birthdate:
Email:
Home Phone:
Mobile Phone:
Address:
City:
State:
Zip:
Gender:
Male
Female
Emergency Contact Name:
Phone:
Financial Party Information
Patient and Financial Party are the same (Primary)
First Name:
Last Name:
Relationship:
Email:
Primary Phone:
Other Phone:
Address:
City:
State:
Zip:
Birthdate:
SSN/ID:
Occupation:
Employer:
Work Phone:
Patient and Financial Party are the same (Secondary)
First Name:
Last Name:
Relationship:
Email:
Primary Phone:
Other Phone:
Address:
City:
State:
Zip:
Birthdate:
SSN/ID:
Occupation:
Employer:
Work Phone:
Dental Insurance
Primary Insurance:
Insured's Name:
SSN/ID:
Group Number:
Secondary Insurance:
Insured's Name:
SSNI/ID:
Group Number:
Medical History
Physician's Name:
Are you taking any prescription/over the counter drugs?
Yes
No
Please list each one:
For Women:
Are you taking birth control pills?
Yes
No
Are you pregnant?
Yes
No
Week #
Are you nursing?
Yes
No
Have you ever had any of the following diseases or medical problems?
Yes
No
Anemia/Radiation
Yes
No
Heart Surgery/ Pacemaker
Yes
No
Kidney Problems
Yes
No
Hemophilia/Abnormal Bleeding
Yes
No
Artificial Valves
Yes
No
Emphysema/Glaucoma
Yes
No
Asthma/Arthritis
Yes
No
High/Low Blood Pressure
Yes
No
Blood Transfusion
Yes
No
Cancer/Chemotherapy
Yes
No
HIV+ AIDS
Yes
No
Hospitalized for Any Reason
Yes
No
Sinus Problems
Yes
No
Artificial Bones/Joints
Yes
No
Mitral Valve Prolapse
Yes
No
Difficulty Breathing
Yes
No
Psychiatric Problems
Yes
No
Drug/Alcohol Abuse
Yes
No
Rheumatic/Scarlet Fever
Yes
No
Ulcer/Colitis
Yes
No
Sever/Frequent Headaches
Yes
No
Hepatitis
Yes
No
Epilepsy/Seizures/Fainting Spells
Yes
No
Fever Blisters/Herpes
Yes
No
Diabetes/Tuberculosis (TB)
Yes
No
Heart Attack/Stroke
Yes
No
Congenital Heart Defect
Yes
No
Heart Murmur
Yes
No
Venereal Disease
Please list any other diagnosis not listed above:
Please list any serious medical condition(s) that you have ever had:
Are you allergic to any of the following
Yes
No
Aspirin
Yes
No
Tetracycline
Yes
No
Penicillin
Yes
No
Any Metal/Plastics
Yes
No
Erythromycin
Yes
No
Latex
Yes
No
Codeine
Yes
No
Dental Anesthetics
Yes
No
Other
Please list any other drugs that you are allergic to:
NOTICE OF PRIVACY PRACTICES
Privacy Officer:
Dionne J. Finlay, DDS
Effective date:
February 6, 2007
This Notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
We care about our patients’ privacy and strive to protect the confidentiality of your medical information at this practice. Federal legislation requires that we issue this official notice of our privacy practices. You have the right to the confidentiality of your medical information, and this practice is required by law to maintain the privacy of that protected health information. This practice is required to abide by the terms of the
Notice of Privacy Practices
currently in effect, and to provide notice of its legal duties and privacy practices with respect to protected health information. If you have any questions about this Notice, please contact the Privacy Officer
Who Will Follow This Notice
Any health care professional authorized to enter information into your medical record, all employees, staff and other personnel at this practice who may need access to your information must abide by this Notice. All subsidiaries, business associates (e.g. a billing service), sites and locations of this practice may share medical information with each other for treatment, payment purposes or health care operations described in this Notice. Except where treatment is involved, only the minimum necessary information needed to accomplish the task will be shared.
How We May Use and Disclose Medical Information About You
The following categories describe different ways that we may use and disclose medical information without your specific consent of authorization. Examples are provided for each category of uses or disclosures. Not every possible use or disclosure in a category is listed.
For Treatment.
We may use medical information about you to provide you with medical treatment or services. For example, in treating you for a specific condition, we may need to know if you have allergies that could influence which medications we prescribe for the treatment process.
For Payment.
We may use and disclose medical information about you so that the treatment and services you receive from us may be billed and payment may be collected from you, an insurance company or a third party. For example, we may need to send your protected health information, such as your name, address, office visit date, and codes identifying your diagnosis and treatment to your insurance company for payment.
For Health Care Operations.
We may use and disclose medical information about you for health care operations to assure that you receive quality care. For example, we may use medical information to review our treatment and services and evaluate the performance of our staff in caring for you.
Other Uses of Disclosures That Can Be Made Without Consent or Authorization
As required during an investigation by law enforcement agencies
To avert a serious threat to public health or safety
As required by military command authorities for their medical records
To workers’ compensation or similar programs for processing of claims
In response to a legal proceeding
To a coroner or medical examiner for identification of a body
If an inmate, to the correctional institution or law enforcement official
As required by the US Food and Drug Administration (FDA)
Other healthcare providers’ treatment activities
Other covered entities’ and providers’ payment activities
Other covered entities’ healthcare operations activities (to the extent permitted under HIPAA)
Uses and disclosures required by law
Uses and disclosures in domestic violence or neglect situations
Health oversight activities
Other public health activities
We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Uses and Disclosures of Protected Health information Requiring Your Written Authorization
Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you give us authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will thereafter no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your authorization, and that we are required to retain our records of the care we have provided you.
Your Individual Rights Regarding Your Medical Information
Complaints
If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer at this practice, or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized or discriminated against for filing a complaint.
Right to Request Restrictions.
You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations, or to someone who is involved in your care or the payment for your care. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. To request restrictions, you must submit your request in writing to the Privacy Officer at this practice. In your request, you must tell us what information you want to limit.
Right to Request Confidential Communications.
You have the right to request how we should send communications to you about medical matters, and where you would like those communications sent. To request confidential communications you must make your request to the Privacy Officer at this practice. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. We reserve the right to deny a request if it imposes an unreasonable burden on the practice.
Right to Inspect and Copy.
You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually this includes medical and billing records but does not include psychotherapy notes, information compiled for use in a civil, criminal, or administrative action or proceeding, and protected health information to which access is prohibited by law. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer at this practice. If you request a copy of the information, we reserve the right to charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by this practice will review your request and the denial. The person conduction the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to Amend.
If you feel that the medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept. To request an amendment, your request must be made in writing and submitted to the Privacy Officer at this practice. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if the information was not created by us, is not part of the medical information kept at this practice, is not part of the information which you would be permitted to inspect and copy, or which we deem to be accurate and complete. If we deny your request for an amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Statements of disagreement and any corresponding rebuttals will be kept on file and sent out with any future authorized requests for information pertaining to the appropriate portion of your record.
Right to an Accounting of Non-Standard Disclosures.
You have the right to request a list of the disclosures we made of medical information about you. To request this list, you must submit your request to the Privacy Officer at this practice. Your request must state the time period for which you want to receive a list of disclosures that is no longer than six years, and may not include dates before December 1, 2006. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, we reserve the right to charge you for the cost of providing the list.
Right to a Paper Copy of This Notice.
You have the right to a paper copy of this Notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy. To obtain a paper copy of the current Notice, please request one in writing from the Privacy Officer at this practice.
Changes to This Notice
We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for medical information we already have about you, as well as any information we receive in the future. We will post a copy of the current Notice with the effective date in the upper right corner of the first page.
NOTICE OF PRIVACY PRACTICES
PATIENT ACKNOWLEDGEMENT
Patient’s Name:
Date of Birth:
I have received this practice’s
Notice of Privacy Practices
written in plain language. The Notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights, how I may exercise these rights, and the practice’s legal duties with respect to my information
I understand that this practice reserves the right to change the terms of its
Notice of Privacy Practices,
and to make changes regarding all protected health information resident at, or controlled by, this practice. I understand I can obtain this office’s current
Notice of Privacy Practices
on request.
Patient/Parent/Guardian Signature
Date:
Relationship to patient (if signed by a personal representative of patient)