NOTICE OF PRIVACY PRACTICES
|
|
|
- Barrie Peters
- 5 years ago
- Views:
Transcription
1
2
3 NOTICE OF PRIVACY PRACTICES This notice describes how health information about you may be used and disclosed and how you can get access to this information PLEASE REVIEW IT CAREFULLY THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US USES AND DISCLOSURES OF HEALTH INFORMATION We may use or disclose health information about you for treatment, payment, and healthcare operations. For example: Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you, or to family or friends you approve. Payment: We may use or disclose your health information to obtain payment for services we provide to you. Healthcare Operations: We may use or disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. You also have the right to request restrictions on disclosure of PHI (Personal Health Information), or alternative means of communication to ensure privacy. Marketing Heath-Related Services: We will not use your health information for marketing communications without your written authorization. Required by Law: We may use or disclose your health information if we are required to do so by law or national security activities. Abuse or Neglect: We may disclose your health information to appropriate authorities when we suspect abuse or neglect. Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voic messages, postcards, or letters). PATIENT RIGHTS Access: You have the right to look at or get copies of your health information with limited exceptions. If you request copies, we will charge you a reasonable fee to locate and copy your information, and postage if you want the copies mailed to you. Amendment: You have the right to request that we amend your health information. Questions and Complaints If you want more information about our privacy practices or if you have questions or concerns, please contact us.
4 If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. Upon request, we can provide you with the address to file your complaint with the U.S. Department of Health and Human Services. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with the U.S. Department of Health and Human Services. A Privacy/Contact Officer has been designated for this office. Please ask our front desk personnel and they will direct you to the Privacy/Contact Officer. PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT FOR NECESSARY USE OF PERSONAL HEALTH INFORMATION Print Patient s Name Date I,, have received (Signature of Patient or Parent or Legal Guardian) a copy of this office s NOTICE OF PRIVACY PRACTICES as required by federal law. I,, consent to the use and disclosure of (Signature of Patient or Parent or Legal Guardian) my personal health information by your office during Treatment, Billing/Payment and Healthcare Operations as outlined in the Notice of Privacy Practices Contact Information: Ira G. Spiro 830 West End Court Suite 800 Vernon Hills, IL
5 Ira G. Spiro, D.D.S Simona Cheskis, D.D.S. 830 West End Court Suite 800 Vernon Hills, IL Financial Policy Payment Full payment is due at the time services are rendered. We do not offer payment plans but we offer CareCredit and Lending Club as an additional method of payment. Returned checks will be charged a $25 fee. Balances over 60 days will be subject to a 10% late fee of the unpaid amount. Delinquent balances over 90 days will be referred to our collection agency and a recovery fee of 30% of the outstanding balance will be incurred. The outstanding balance will have to be paid in full for the patient to continue receiving dental treatment in our office. Insurance As a courtesy to our patients, we will submit your dental insurance. However, the patient is ultimately responsible for payment even if the claim is rejected. Due to the complexity of insurance contracts, we can only estimate in good faith. Estimated patient portion is expected at the time service is delivered. If the insurance company does not pay the anticipated amount, the patient is responsible for the difference. If you have any questions regarding your account, feel free to call our office for an explanation. I have read, understand and agree to comply with the above policy Patient Name Patient/Guardian Signature Date Ira G. Spiro, D.D.S Simona Cheskis, D.D.S. 830 West End Court Suite 800 Vernon Hills, IL 60061
6 Cancellation/No Show Policy We understand that unplanned issues can come up and you may need to cancel an appointment. If that happens, we respectfully ask for scheduled appointments to be cancelled AT LEAST 24 HOURS IN ADVANCE. Our doctors and hygienists want to be available for your needs and the needs of all our patients. When a patient does not show up for a scheduled appointment, another patient loses an opportunity to be seen. Thank you for being a valued patient and for your understanding and cooperation! 1 st time - Warning 2 nd time - $50 Fee 3 rd time - $50 fee and possible termination from practice I have read, understand and agree to comply with the above policy Patient Name Patient/Guardian Signature Date
FINANCIAL POLICY 1. Patients with Dental Insurance 2. Self Pay Patients 3. Billing
FINANCIAL POLICY Our office has always made it a priority to provide the highest quality of care to all patients, with an on time philosophy. The ability to deliver quality services by highly competent
Notice Of Privacy Practices
HIPAA PRIVACY FORM 1 Notice Of Privacy Practices Purpose: This form, Notice of Privacy Practices, presents the information that federal law requires us to give our patients regarding our privacy practices.
First&Appointment& Medical&History& Recall&Appointments& Cancelled/Failed&Appointments& Payments& Insurance&
Communication*is*important*to*us*as*a*part*of*your*complete*dental*care.**Please*take*a* moment*of*your*time*to*review*our*policies.* First&Appointment& Your%first%appointment%will%consist%of%a%full%mouth%series%of%x4rays%and%a%full%oral%exam.%%If%you%have%any%
Appointment Policy. Insurance Policy
Appointment Policy Broken dental appointments are a disappointment to everyone. They interfere with dental treatment and create unnecessary scheduling problems for patients as well as the office. We attempt
Singh Family Dental Dr. P. Singh, PLLC
Singh Family Dental Dr. P. Singh, PLLC 25 Country Club Road, #301 Gilford, NH 03249 (603)524-7455 251 Mayhew Turnpike Plymouth, NH 03264 (603)536-7600 260 Route 16B Center Ossipee, NH 03814 (603)539-4995
New Patient Information and Forms
350 S. Providence Rd. New Patient Information and Forms Please review, print, and sign the enclosed documents in advance of your first appointment. Our office staff will be happy to address any questions
St. Michael Dental Posthumus & Biorn, Inc.
St. Michael Dental Posthumus & Biorn, Inc. THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE
Notice of Privacy Practices
This Notice describes how your health information may be used and disclosed and how you can get access to this information. Please review it carefully. The privacy of your health information is important
Our philosophy of care governs everything we do for you. It consists of the following key elements:
Welcome to our office! We appreciate the confidence and trust that you have placed in us and look forward to meeting you personally and professionally. Our philosophy of care governs everything we do for
SMILE ANALYSIS. How s Your Smile? YES NO (Look in the mirror as you answer these questions)
Edward J. Smith, D.M.D. Family, Cosmetic and Implant Dentistry Did You Know? SMILE ANALYSIS 9 out of 10 Americans agree that an attractive smile is an important asset ¾ of Americans agree that an unattractive
GETTING TO KNOW YOU. 1. How important is it for you to keep your teeth healthy for a lifetime?
Robert W. Renger, D.D.S., L.L.C. 510 W. 32 nd St. Joplin, MO 64804 417-781-6700 GETTING TO KNOW YOU 1. How important is it for you to keep your teeth healthy for a lifetime? 2. If you could change one
Sparta Dental Center Office Policy Statement
Sparta Dental Center Office Policy Statement Our practice believes in the theories of modern dental care. Through proper preventive care and regular checkups, we believe that it is highly likely that most
Regulatory Compliance
Regulatory Compliance Sample Notice of Privacy Practices A covered entity has until September 23, 2013 to update its notice of privacy practices with the 2013 HIPAA amendments. An article on the CDA Practice
Notice of Privacy Practices
David K Buran, D.M.D., PC Notice of Privacy Practices THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
LITTLE ROCK FAMILY DENTAL CARE
LITTLE ROCK FAMILY DENTAL CARE As a COURTESY to our patients, our office will file your insurance claims in a timely manner. We are only providers for DELTA DENTAL, METLIFE, BLUE CROSS BLUE SHIELD OF AR,
NOTICE OF PRIVACY PRACTICES
NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR
Fairview Dental. Patient Information: Patient First Name: MI: Last: Preferred Name: Date of birth: SS#: Address: City: Zip: Home Ph: Cell: :
Patient Information: Fairview Dental Date: Patient First Name: MI: Last: Preferred Name: Date of birth: SS#: Address: City: Zip: Home Ph: Cell: : Email: Check one : Child Single Married Divorced Widowed
Welcome to a Brighter Morgantown!
Welcome to a Brighter Morgantown! New Patient Information Payment Options E X C E L L E N C E I N D E N T I S T R Y S I N C E 1 9 2 7 Welcome to a Brighter Morgantown! Morgantown Dental Group would
Consent for Services and Financial Policy
Consent for Services and Financial Policy As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for
Patient Information Patient Info. Update
Medical History Brian R. Carr, D.D.S., M.D Patient Information Gagandeep Pandher,D.D.S. Patient Info. Update Date Date Initials Date Initials Name Address Cell Phone # City State Zip Work # Date of Birth
Picasso Aesthetic and Cosmetic Dental Spa NOTICE OF PRIVACY PRACTICES
NOTCE OF PRVACY PRACTCES THS NOTCE DESCRBES HOW HEALTH NFORMATON ABOUT YOU MAY BE USED AND DSCLOSED AND HOW YOU CAN GET ACCESS TO THSNFORMATON. Please review it carefully THE PRVACY OF YOUR HEALTH NFORMATON
Home Phone Work Phone Cell Phone In the event of an emergency, who should we contact? Name Relationship Emergency Contact Phone
Roosevelt Dental, P.A. Gene Kim, d.d.s. WELCOME Thank you for selecting Roosevelt Dental. To help us best meet your health care needs, please complete this form as accurately as possible. Thank you. This
Patient Information. Last First MI (Preferred Name) Male Female Married Single Child. City State Zip Code Emergency Contact/Relation Phone
LEWIS C. COLE DMD Family and Cosmetic Dentistry 525 ENERGY CENTER BLVD SUITE 1603 NORTHPORT, AL 35473 PHONE 205.344.6900 FAX 205.344.6910 www.lewiscoledentistry.com Patient Name: Patient Information Date:
NEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Last Name: Title: First Name: Middle Name: Nick Name: Marital Status: Address: City State Zip Code Home Phone: Work Phone: Cell Phone: SS#: DOB: Sex: Referring Dr: Referring
Germantown Smiles,PC Germantown Road Suite 225 Germantown, Maryland
Germantown Smiles,PC 19735 Germantown Road Suite 225 Germantown, Maryland 20874 240-654-3302 Patient Information Patient Name: Last First MI Gender: Male Female Family Status: Married Single Child Other
Please check if patient is a minor/child. First Name: Last Name: Middle Initial: Preferred name: Address: City: State: Zip: Home: Work: Cell:
Guest Form Jon M Van Slate, DDS,FAGD,LVIF 1011 Augusta Dr, Suite 201 Houston, Texas 77057 (713) 783-1993 info@drvanslate.com www.drvanslate.com Patient Information Please check if patient is a minor/child
York Smile Care. First: Middle: Last: Jr/Sr: Street: City: State Zip: Home Phone: Work Phone: Cell Phone: Patient's Employer:
Patient Information Circle One: Dr/Mr/Mrs/MS/Miss First: Middle: Last: Jr/Sr: Street: City: State Zip: Home Phone: Work Phone: Cell Phone: Patient's Employer: Email Address: May we contact you by Email(circle)
Connecticut Asthma & Allergy Center LLC Registration Form
Name: Connecticut Asthma & Allergy Center LLC Registration Form Last First Middle Initial Date of Birth: / / Sex: Race: Ethnicity: Language: SS#: xxx-xx- Address: # Street Apt/PO Box Email: Town State
425 North Wendover Road Charlotte, NC Birthdate: Social Security #: Male Female
425 North Wendover Road Charlotte, NC 28211 PATIENT INFORMATION: Patient s Legal Name: Nickname: Birthdate: Social Security #: Male Female Status: Minor (under 18) Single Married Separated Divorced Widowed
Medical History. Authorization to Treat. Financial Policy. Notice of Privacy Practice
Authorization to Treat Financial Policy Medical History Notice of Privacy Practice Authorization to Treat Patient Name I authorize Dr. Gregory C. Thiel to perform a complete dental examination and procure
Patient Information. Name Soc. Sec. # Last Name First Name Middle Initial. Address. City State Zip. Home Phone Cell Phone
Patient Information NameSoc. Sec. # Last Name First Name Middle Initial Address City State _ Zip _ Home Phone _ Cell Phone _ Sex M F Birthdate _ Single Married Widowed Separated Divorced Patient Employed
LANCE OSBORNE DENTISTRY LANCE OSBORNE, DDS SCOTT ZIMMEREBNER, DDS 245 Van Asche Loop Fayetteville, Arkansas
LANCE OSBORNE, DDS SCOTT ZIMMEREBNER, DDS Patient Information Patient Name: Date: Last First Mi Preferred Gender(M/F): Marital Status: Birth Date: Social Security # Driver s License#: E-Mail Address: State
First Name: Last Name: Initial:
Patient Information Sheet Please complete the entire form First Name: Last Name: Initial: Address: City: State: Florida Zip Code: Home: ( ) Work: ( ) Cell: ( ) 420 South Dixie Hwy, Suite 4D Email: Gender:
OFFICE FINANCIAL POLICY
OFFICE FINANCIAL POLICY DDS Baltazar Guzman In our continue commitment to provide the highest quality dental care available to all of our patients and to have those services comfortably affordable, we
HAROLD GOODMAN, D.O SECOND AVENUE SUITE 405B SILVER SPRING, MD Patient Information
Patient Information Name birth date Address (street) apt. # (town, state, zip) Telephone: home cell phone Guardian (if a minor) work e-mail relationship Address (if different) telephone Employer Occupation
CHILDREN S DENTISTRY OF RANCHO CUCAMONGA Welcome to our practice!
CHILDREN S DENTISTRY OF RANCHO CUCAMONGA Welcome to our practice! We strive to make each of your child s visits pleasant and comfortable. Our goal is to teach your child oral habits which will help keep
Conte See Oue Exei^ing
CoDcorcf %di^tvic D Dtisti?y 16 foundry Itreet, Co^corcf Conte See Oue Exei^ing nolttel Immediately off 1-93 at Exit 16 (see directions below) Please call our office for details. Direct Jons From North:
Name Relationship Did you hear about us in any other way?
PATIENT INFORMATION Personal Information Patient s Name Today s Date Nickname/Preferred Name (if any) Birth date S.S. # - - Status (please circle) Child / Adult Single Married Divorced Widowed Parent s/spouse
PATIENT REGISTRATION AND MEDICAL HISTORY (PLEASE PRINT IN BLACK INK ONLY)
PATIENT REGISTRATION AND MEDICAL HISTORY (PLEASE PRINT IN BLACK INK ONLY) Whom can we thank for referring you ( ) Insurance Co. ( ) Advertisement ( ) Our existing patient (provide name) E-mail Cell Phone
NOTICE OF PRIVACY PRACTICES
San Antonio Oral & Maxillofacial Surgery Associates, P.A. www.saomsa.com NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
Doc Bresler s Cavity Busters - New Patient History Form
Doc Bresler s Cavity Busters - New Patient History Form Patient s Name Nickname Date of Birth Age Female Male Address City,State,Zip Code Home Phone Mother s Name Occupation Email Address Cell Phone Father
1984 Isaac Newton Sq. W. #100 Reston, VA Patient Information
Patient Information Patient s Last Name First Name Middle Initial Preferred Name Responsible Party s Name (if not patient) Relationship to the patient Today s Date Family Status: Single Married Divorced
First Name: Middle Name: Last Name: Preferred Name: Address: City: State: Zip: Mother s First & Last Name: Mother s Home Phone: Mother s Work Phone:
Patient Information First Name: Middle Name: Last Name: Date of Birth: Gender: M F Preferred Name: Address: City: State: Zip: Contact Information Mother s First & Last Name: Mother s Address (If different
Need help with frequent crisis, housing, transportation?
Need help with frequent crisis, housing, transportation? Kentucky Counseling Center will provide help FREE of charge to qualifying Medicaid recipients. Our Case Management program may assist in the following
Acknowledgement of Receipt of Notice of Privacy Practices
Acknowledgement of Receipt of Notice of Privacy Practices **You may refuse to sign this acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. Signature: : Release of
SUMMARY OF NOTICE OF PRIVACY PRACTICES
SUMMARY OF NOTICE OF PRIVACY PRACTICES This summary is provided to assist you in understanding the attached Notice of Privacy Practices The attached Notice of Privacy Practices contains a detailed description
New Beginning Pediatric Rehab ~ Maryland s Trusted Rehabilitation Practice ~ (410) Office (877) Fax
PATIENT/PARENT INFORMATION Patient Full Name: Patient s Date of Birth: Parent(s) Name: Cell Number: Address: Home Number: Email: How did you hear of us? (Physician,Google,Friend,Yellow Pages,Other) Authorized
Important Facts Regarding Our Practice
Important Facts Regarding Our Practice CANCELLATION or BROKEN APPOINTMENTS: Our time is as valuable as yours and the other patients scheduled to come in. We are able to extend a no charge fee to our patients
EFFECTIVE DATE OF THIS NOTICE: 8/5/09
NOTICE OF PRIVACY PRACTICES EFFECTIVE DATE OF THIS NOTICE: 8/5/09 THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
Is this your child s first visit to the dentist? Yes No If no, date of: last exam dental x-rays fluoride treatment
PATIENT HEALTH INFORMATION The following information is requested to enable us to give the most consideration to your time and feelings. It is our sincere desire to give personal attention to each of our
PATIENT INFORMATION. Name of child Date of Birth Age Sex Last First Middle Preferred Name (Nickname) HomeAddress Street City State Zip
Welcome to! We are pleased to welcome you and your child to our practice. Please take a few minutes to fill out these forms as completely as you can. If you have questions we will be glad to help you.
All Dental 76 Otis Street Westborough, MA 01581
All Dental 76 Otis Street Westborough, MA 01581 Date: SSN: Primary Care Physician: Physician Phone: Patient Information Patient Name: Last First Address: City: State: Zip: Birthday: / / Employer: Occupation:
SUMMARY OF NOTICE OF PRIVACY PRACTICES
SUMMARY OF NOTICE OF PRIVACY PRACTICES This summary is provided to assist you in understanding the attached Notice of Privacy Practices The attached Notice of Privacy Practices contains a description of
PATIENT REGISTRATION & HEALTH HISTORY FORM
PATIENT REGISTRATION & HEALTH HISTORY FORM 133 E Main Street, Carlton, OR 97111 Phone: (503) 852-7147 Date: PATIENT INFORMATION First Name: M: Is the patient a student? Full Time Part Time Last Name: Employer:
Thomas Yoon Dental Patient Information. Health Information
Patient Name: Thomas Yoon Dental Patient Information Last First MI (Preferred Name) Social Security #: Date of Birth: / / Gender: Male Female Marital status: Phone # (Home): (Cell): (Work): Ext: E-mail
Kathy A Curtis DDS, PLLC Downtown Dentistry
Kathy A Curtis DDS, PLLC Downtown Dentistry Office Policy We are committed to forming a partnership with you to provide excellent dental care. To help achieve this goal, we need your cooperation and understanding,
Our portals are encrypted and password-protected, too, so health data remains secure.
Patient Portal Education Sheet We know you re busy. That s why Palmetto Health-USC Medical Group s physician practices are offering a way for you to manage your health care online. We offer convenient
Agile Mind Counseling 506 Maple Street A Wellness Approach Athens, Tn
Notice of Privacy Practices Receipt and Acknowledgment of Notice Client 1 Client Name: Date of Birth: Patient Signature: Today s date: Client 2 Client Name: Date of Birth: Patient Signature: Today s date:
Child Health/Dental History Form
Child Health/Dental History Form Patient s Name Nickname Date of Birth LAST FIRST INITIAL Parent s/guardian s Name Relationship to Patient Address PO OR MAILING ADDRESS CITY STATE ZIP CODE Phone Sex M
Your Physical health is: Good Fair Poor Are you currently under the care of a physician? Yes No Please explain:
Dental History Medical History Reason for today s visit: _ Former Dentist:_ Date of last dental visit_ Date of last dental x-rays_ Mark Yes or No to indicate if you presently have or previously had any
Permission to Discuss Medical Information HIPPA PATIENT ACKNOWLEDMENT. Patient Name:
Patient Name: HIPPA PATIENT ACKNOWLEDMENT (Must be filled out by a parent/guardian if the patient is under the age of 18) We are required by law to maintain the privacy of protected health information
New Patient Information Form
PATIENT INFORMATION New Patient Information Form Patient s Patient s Preferred Name Middle Initial Date of Birth SSN# Primary Language YES NO Email Address Race/Ethnicity Is patient of Hispanic Origin?
Center for Emotional Wellness & Healing, LLC 100 Heritage Valley Rd, Ste. 1, Sewell, NJ 08080
100 Heritage Valley Rd, Ste. 1, Sewell, NJ 08080 INTAKE FORM Name: DOB: Age: Street: City/Town: Zip Code: Home Phone: May We Leave a Message? Yes No Cell Phone: May We Leave a Voice Message? Yes No May
X X Capistrano Children s Dentistry Child Patient Information
X X Capistrano Children s Dentistry Child Patient Information Your Child Name: Nickname: Home Address: Birthdate: Age: Sex: Home Phone: School: Pediatrician: Please list names of other siblings previously
Welcome To. Concord Pediatric Dentistry. First Middle Last. Street City State Zip. Dental Insurance Information
Welcome To Concord Pediatric Dentistry Patient Information Patient s Name: First Middle Last Name child goes by: Sex: Mailing Address Street City State Zip Date of Birth: Age: Weight: Child Lives with:
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM NAME: Age: DATE OF BIRTH: SSN: Sex: MARITAL STATUS: PRIMARY CARE PHYS: DRIVER S LICENSE # STATE IF CHILD, GUARDIAN S NAME: ADDRESS: City State Zip Code PHONE: Home Phone Cell Phone
Regulatory Compliance
Regulatory Compliance Sample Notice of Privacy Practices - Layered A covered entity has until September 23, 2013, to update its notice of privacy practices with the 2013 HIPAA amendments. An article on
HIPAA Notice of Privacy Practices
HIPAA Notice of Privacy Practices THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This HIPAA Notice
Consent for Purposes of Treatment, Payment and Healthcare Operations
Consent for Purposes of Treatment, Payment and Healthcare Operations I consent to the use or disclosure of my protected health information by Neuropsych Associates for the purpose of diagnosing or providing
PATIENT INFORMATION PARENT / GUARDIAN INFORMATION
PATIENT INFORMATION Child s name: Nickname: Age: Birth date: Male/ Female Names and ages of siblings: Home address: City/State/Zip: Telephone: Child s School: Child s Physician: Address & Phone Number:
Just for Kids Pediatric Dentistry, Ltd. Patient Information
Date Just for Kids Pediatric Dentistry, Ltd. Patient Information Child s Name Age Date of Birth Parents Names Address City Zip Parent s Marital Satus (M) (S) (D) With whom do the children reside? Telephone:
Northwest Ohio Orthopedics and Sports Medicine, Inc CR 236 Findlay, Ohio
Northwest Ohio Orthopedics and Sports Medicine, Inc. 7595 CR 236 Findlay, Ohio 45840 419-427-1984 Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
Patient Information: Date: Name: Married Single Minor Male Female Last First Middle Preferred. Birth date: S.S.N.# ID/DL#: Month /Day /Year
Patient Information: Date: Name: Married Single Minor Male Female Last First Middle Preferred Birth date: S.S.N.# ID/DL#: Month /Day /Year Address: Street Apt. # City State Zip Telephone: Home # Work#
or provide a seperate list
or provide a seperate list I have been offered a copy of the Notice of Privacy Practices. I understand that Executive Cardiac Arrhythmia Solutions has the right to change its Notice of Privacy Practices
Notice of Privacy Policies
Notice of Privacy Policies THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THIS NOTICE BECAME EFFECTIVE
DAHL DENTISTRY. 46 PARK PLACE, SUITE A BRANFORD, CT (203) (203) FAX
MEDICAL HISTORY Please fill out this form as completely as possible. This information is essential for our staff to provide dental care in a manner that is compatible with your general health. Your cooperation
MANUAL OF UNIVERSITY POLICIES PROCEDURES AND GUIDELINES. Applies to: faculty staff students student employees visitors contractors
Number: Page 1 of 12-3 14 Applies to: faculty staff students student employees visitors contractors Effective Date of This Revision: September 23, 2013 Contact for More Information: Chief Privacy Officer
Child s Name: Last First Middle Preferred Name. Address: Street Apt.# City State Zip. Mother Stepmother Guardian. Name: Employer: Social Security #:
Today s Date We are so pleased to welcome you and your child to our practice. Please take a few minutes to fill out this form as completely as you can. If you have any questions, we ll be glad to help
Patient ad t Information. Insurance Information. Dental History
Patient ad t Information Full Name Preferred Name Birth Date / / Age Today s Date Mailing Address Street Address Home Phone ( ) Cell Phone ( ) Email Check Appropriate Box: Minor Single Married Divorced
Trinity Family Physicians
Trinity Family Physicians Consent and Authorization for Minors By law, a healthcare provider must attempt to contact a birth / custodial parent or legal guardian prior to rendering treatment to a minor
FOOTHILLS SPORTS MEDICINE PHYSICAL THERAPY. PATIENT REGISTRATION FORM Please Print
FOOTHILLS SPORTS MEDICINE PHYSICAL THERAPY PATIENT REGISTRATION FORM Please Print Patient Name: Patient Social #: Gender: [ ] Male [ ] Female Birth Date: Age: Address: City, State, Zip: Home Phone: Cell
PRIVACY NOTICE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
1NovaMed Surgery Center of Maryville, LLC PRIVACY NOTICE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
M F Last Name First Name Middle Initial Gender. Home Phone: Work Phone: Cell Phone: Physical Address: Mailing Address (if different):
Welcome to Patient Information: Date of Birth: M F Last Name First Name Middle Initial Gender Home Phone: Work Phone: Cell Phone: Physical Address: Mailing Address (if different): Employer: Occupation:
Spink Dentistry New Patient Questionnaire: Patient Name: Cell: General check-up Toothache Veneers. Cavity or Filling Implant Crown or Bridge
Spink Dentistry 4005 Crosshaven Drive Birmingham, AL 35243 Phone: 205-967-8555 Fax: 205-968-0202 beth@spinkdentistry.com Spink Dentistry New Patient Questionnaire: Date: Patient Name: Date of Birth: Social
FOOTHILLS SPORTS MEDICINE AND REHABILITATION. PATIENT REGISTRATION FORM Please Print
PATIENT REGISTRATION FORM Please Print Patient Name: Patient Social #: Gender: [ ] Male [ ] Female Birth Date: Age: Address: City, State, Zip: Home Phone: Cell Phone: Work Phone: Authorization to leave
My Scottsdale Dentist. Patient Name: Date: Address: Birth Date: Gender (circle): M / F Family Status (circle):
My Scottsdale Dentist Patient Name: Date: Address: Birth Date: Gender (circle): M / F Family Status (circle): Single / Married / Other: Spouse/Domestic Partner Name: Tel. No.: Social Security # Driver
CREEKSIDE DENTAL REGISTRATION FORM. Please Print PATIENT INFORMATION. Patient s Last Name: First: Middle:
Today s date CREEKSIDE DENTAL REGISTRATION FORM Please Print PATIENT INFORMATION Patient s Last Name: First: Middle: Home Phone #: Work #: Cell #: Email Address: Street Address: City: State: Zip Code:
Would you like to receive s with special offers from Carolina Vein Center? yes no
Carolina Vein Center Patient Information Name: Date: Address: Home Phone: City: State: Zip: Work Phone: SS#: Marital Status: Occupation: Date of Birth: _ Cell Phone: Emergency Contact: E-Mail: Emergency
Cardiology Consultants of Atlanta, P.C N. Decatur Rd. Suite 395, Decatur GA, (404) phone (678) fax
OFFICE POLICIES AND PROCEDURES Thank you for choosing Cardiology Consultants of Atlanta for your cardiovascular care. We realize that you have a choice in medical providers and are pleased that you have
Jody Finazzo,dds, ms
Jody Finazzo,dds, ms Child & Adolescent Dental Specialist Dear Parent, Welcome to our practice! We appreciate the trust you have shown in us by selecting our practice to provide your child s dental care.
Cosmetic Dental Concerns
Cosmetic Dental Concerns With recent advancements in materials and techniques, many of our patients are inquiring about cosmetic dental procedures. In order to better serve you, please take a moment to
UNITED WORKERS HEALTH FUND 50 CHARLES LINDBERGH BLVD. SUITE 207 UNIONDALE, NY 11553
UNITED WORKERS HEALTH FUND 50 CHARLES LINDBERGH BLVD. SUITE 207 UNIONDALE, NY 11553 Tel: 516-740-5325 tnl@dickinsongrp.com Fax: 516-740-5326 REVISED NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW
FOOTHILLS SPORTS MEDICINE AND REHABILITATION. PATIENT REGISTRATION FORM Please Print
FOOTHILLS SPORTS MEDICINE AND REHABILITATION PATIENT REGISTRATION FORM Please Print Patient Name: Patient Social #: Gender: [ ] Male [ ] Female Birth Date: Age: Address: City, State, Zip: Home Phone: Cell
ADKINS CHIROPRACTIC LIFE CENTER 157 KEVELING DRIVE SALINE, MICHIGAN Notice of Patient Privacy Policy
ADKINS CHIROPRACTIC LIFE CENTER 157 KEVELING DRIVE SALINE, MICHIGAN 48176 734 429 2410 Notice of Patient Privacy Policy This notice describes how medical information about you may be used and disclosed,
PATIENT INFORMATION. Name: Last First Middle Initial Nickname D.O.B. Social Security#: Marital Status: Sex: Male or Female Address:
PATIENT INFORMATION Name: Last First Middle Initial Nickname D.O.B. Social Security#: Marital Status: Sex: Male or Female Address: City: State: Zip Code: Employment Status: Employer: Employer Address:
Betty Kratzenberg, MS, LMFT INITIAL CLIENT INFORMATION
Betty Kratzenberg, MS, LMFT INITIAL CLIENT INFORMATION Client Information: First MI Last Address City ST Zip Home ( ) Work ( ) Cell ( ) Okay to call or leave message at: home: Yes No work: Yes No SS# DOB
Secondary Insurance Co. Name & Address: Subscriber s Name: Subscriber Soc. Sec. No. Group number:
M a u r i c i o R o n d e r o s, D D S, M S, M P H I. PATIENT INFORMATION: Last Name: First Name: MI: Mr. Mrs. Ms. Male Female Birth date (M/D/Y): Marital status: Dr. Other: Address: City, State: Zip:
Patient Information DOB. Female Male Single Married Divorced Widowed. Address City State Zip Code. SSN Home Phone Cell Address
Patient Information Patient Name Date First Middle Last DOB Nick Name Female Male Single Married Divorced Widowed SSN Home Phone Cell Email Primary Insurance Carrier Policy Holder Name Relationship to
Patient registration. MyIdealDental.com. Primary insurance information. Secondary insurance information
Patient registration Patient ID Chart ID Medicaid ID Employer ID First Name Last Name Member ID Carrier ID Preferred Name Middle Initial Patient is: Primary policy holder Responsible Party is: Primary
HIPAA PRIVACY NOTICE CONSENT FORM HIPAA AUTHORIZATION TO DISCUSS YOUR MEDICAL INFORMATION
HIPAA PRIVACY NOTICE CONSENT FORM I understand and have been provided with Premier Allergy s Notice of Privacy Practices that provides a more complete description of information uses and disclosures. Premier