Wainwrightortho_Patient_Information

WAINWRIGHT ORTHODONTICS

Brandon M. Wainwright, DDS

I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be use to:

Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly and indirectly
Obtain payment from third party sources.
Conduct normal healthcare operations such as quality assessments and physician certifications.

I may request a copy of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such, prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request, in writing, that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

By providing us with your wireless/cell phone number, you are hereby granting us, and our agents or independent contractors, your consent to receive calls on your wireless/cell phone for billing and debt collection purposes.

Patient Name

Date

Patient Signature

Signature of Responsible Party if minor

Relationship

WAINWRIGHT ORTHODONTICS

Brandon M. Wainwright, DDS

The Health Insurance Portability & Accountability Act of 1996 (HIPPA) provides privacy protections to your medical records. Our benefits office (or other third party designated by our office) may sometimes need to disclose medical information or payment information protected by HIPAA in relation to our group health plans to your family members or close friends involved in your health care. For example, your spouse may need to contact us if you are in the hospital to determine whether a particular procedure is covered under our group health plan. Or may need assistance filing a claim for medical services. Under HIPAA, unless you specifically object, we are allowed to use our professional judgement in deciding whether to discuss your medical and payment information with your family members or close friends. However, we would like to provide you with the opportunity to tell us with whom we may discuss your medical or payment information under our group health plans.

Please list below whom we may or may not discuss your account information with.

You may communicate with the following individuals relating to my medical or payment information:

Please do not discus my medical or payment information with the following individuals:

WAINWRIGHT ORTHODONTICS

Bettendorf · LeClaire · Moline · Sterling

Patient Information

Responsible Party Information

Orthodontic Insurance Information

Primary

Secondary

Medical and Dental History

Medical

Dental

Your “Smile” Questionnaire

Signature

WAINWRIGHT ORTHODONTICS

Brandon M. Wainwright, DDS

WAINWRIGHT ORTHODONTICS

Brandon M. Wainwright, DDS