Dr. Paul Rappaport, D.M.D 2963 Madison Street Carlsbad, CA (760)

Transcription

1 Dr. Paul Rappaport, D.M.D 2963 Madison Street Carlsbad, CA (760) PATIET IFORMATIO ame Birth date Social Security Address City State Zip Please Circle One: Married Separated Widowed Divorced Single Minor Sex: Male Female Cell Phone ( ) Home Phone ( ) Patient s or Parent s Employer Spouse or Parent s ame Phone ( ) Whom may we thank for referring you Person to contact in case of emergency Phone ( ) RESPOSIBLE PARTY ame of Person Responsible for this Account Address Home Phone ( ) Employer Cell Phone ( ) ISURACE IFORMATIO ame of Insured Birthday Social Security # Date Employed Employer Work Phone ( ) Employer Address City State Zip Insurance Company Group # Address City State Zip SECODARY ISURACE IFORMATIO ame of Insured Birthday Social Security # Date Employed Employer Work Phone ( ) Employer Address City State Zip Insurance Company Group # Address City State Zip

2 MEDICAL HISTORY Physician s ame Date of last visit Have you had any serious illnesses or operations? If yes, describe Have you ever taken any anti-resorptive medication to treat osteoporosis or other bone disease? Have you taken alendronate (Fosamax), risedronate (Actonel), received intravenous bisphosphonates (Aredia or Zometa)? Y (Women OLY) Are you pregnant? ursing Taking birth control pills Please answer yes or no to the following: Angina Heart Disease Pacemaker Heart Attack Heart Murmur Mitral Valve Prolapse Low Blood Pressure High Blood Pressure Thyroid Problems Stroke Headaches Joint Replacement Cancer/Chemotherapy Anemia Abnormal Bleeding Blood Transfusion Liver Disease Radiation Therapy Autoimmune Disease Sexually Transmitted Disease Hepatitis A/B/C Diabetes Type I/II Rheumatic Fever Arthritis Asthma Emphysema Recent Weight Loss Sinus Trouble Y Tuberculosis Ulcers Jaundice Epilepsy Fainting Spells AIDS or HIV Infection Mental Health Respiratory Problems Kidney Disease Hay Fever/Allergies Osteoporosis Glaucoma Other Y Are you allergic to any of following? Aspirin Penicillin Codeine Local Anesthetics Acrylic Metal Latex Sulfa Drugs Other If yes, please explain: List medications you are currently taking: Sleep History Questionnaire Please answer yes or no to the following: Do you snore? Do you have unexplained awakenings from Sleep? Do you awaken from sleep gasping for air or choking? Do you wake up exhausted lacking energy? Do you have a headache upon waking in the morning? Do you find it difficult to stay awake during the day? Do you use a CPAP machine when sleeping? Are you currently using any medication to help you sleep? To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health. Signature Date

3 DETAL HISTORY Reason for today s visit Former Dentist Date of last dental care Date of last dental X-rays Are you having pain or discomfort at this time? Have you had a bad experience with previous dental treatment? How often do you floss? How often do you brush? Please answer yes or no to any of the following: Bad breath Difficulty opening Mouth TMJ problems Bleeding gums Clicking or popping jaw Food collection between the teeth Grinding teeth or clenching teeth Periodontal treatment Sensitivity to cold, hot, or sweets Sores or growths in your mouth Dental Questionnaire If you could change anything about your smile which of the following would you want? (Check all that apply) Whiter Close space or spaces Replace chipped teeth Replace missing teeth Replace old crowns Remove silver fillings Less gum showing Remove stains/spots on teeth Straighter Reshape/resize my teeth In presenting your treatment plan and talking to Dr. Rappaport, please let us know which is best for you? I like lots of information and details I like just the basics and facts

4 DETAL TREATMET COSET AD FIACIAL POLICY Dental Consent: I consent to a dental examination and treatment by Dr. Paul Rappaport D.M.D. and such other members of his staff as he designates as assistants. Financial Policy: It is important to us that the quality of our business services matches the quality of dental care. We want the handling of your account to be perceived as an extension of the dental care we provide to you and your family. As with any partnership, both parties have a role to play. Our role is to provide you with quality treatment and service. In turn, your role is to pay your estimated portion which is due upon completion of services. You are financially responsible for any services at this office. As a courtesy to our patients we are happy to file your insurance claim. Please remember that the insurance contract is between you and your insurance carrier. Cancellation fee: Dr. Rappaport, D.M.D. reserves the right to charge for any no show appointments or appointments not cancelled within 48 hours a fee of $50.00 per hour of appointment time scheduled. AUTHORIZATIO AD RELEASE We file insurance claims for all patients with insurance benefits however the balance is your responsibility whether your insurance company pays or not. We cannot bill your insurance without complete insurance information. Your insurance is a contract between you and your insurance company and we are not a party to the contract. If your insurance has not paid on your claim within 45 DAYS, the full balance will automatically be transferred to you. That balance will be due upon billing. I certify that I have read the foregoing (or that it has been read to me) and I fully understand it. I give my consent for examination and treatment and agree to the above conditions for each visit I make to Dr. Paul Rappaport D.M.D. Patient Signature: Date:

5 Paul Rappaport, DMD 2963 Madison Street Carlsbad, CA (760) otice 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. Uses and Disclosures of Health Information We use and disclose health information about you for treatment and payment. Treatment: We disclose medical information to our employees and others who are involved in providing the care you need. We may use or disclose your health information to another dentist or other healthcare providers providing treatment that we do not provide. We may also share your health information with a pharmacist in order to provide you with a prescription, with a laboratory that performs tests or fabricates dental prostheses and orthodontic appliances. Payment: We may include your health information with an invoice used to collect payment for treatment you receive in our office. We may do this with insurance forms filed for you in the mail or sent electronically. We will be sure to only work with companies with a similar commitment to the security of your health information. To Your Family and Friends: We may share your health information with those you tell us will be helping you with your treatment, medications, or payment. We will be sure to ask your permission first. In the case of an emergency, where you are unable to tell us what you want, we will use our best judgment when sharing your health information only when it will be important to those participating in providing your care. Unsecured We will not send you unsecured s pertaining to your health information without your prior authorization. If you do authorize communications via unsecured , you have the right to revoke the authorization at any time. Change of Ownership: If this dental practice is sold or merged with another practice or organization, your health records will become the property of the new owner. However, you may request that copies of your health information be transferred to another dental practice. Required by Law: Your health information will be disclosed when we are required by law to do so. Public Health: We may be required to disclose to Federal officials or military authorities health information necessary to complete an investigation related to public health or national security. Appointment Reminders: We may contact you to provide you with appointment reminders via voic , and text messaging. We may also leave a message with the person answering the phone if you are not available. Patient Rights Your Health Information: You have the right to read, review, and copy your health information which includes: your complete chart, x-rays and billing records. If you would like a copy of your health information, please let us know. We may need to charge you a reasonable, costbased fee to duplicate and assemble your copy. If there will be a charge, we will first contact you to determine whether you wish to modify or withdraw your request. Access and Restrictions: You have the right to request restrictions on the use or disclosure of your health information for treatment and payment in addition to the restrictions imposed by federal law. Our office is not required to agree to your request, unless you request that we not disclose your information to a health insurance company for payment. Our office will honor your request that we not disclose your health information to a health plan for payment if the health information relates solely to a healthcare item or service for which you have paid us out-of-pocket in full. Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended). We may deny your request under certain circumstances. Request a Copy: You have the right to obtain a copy of this otice of Privacy Practices directly from our office at any time. Stop by or give us a call and we will mail or a copy to you. Breach otification: In the event your unsecured protected health information is breached, we will notify you as required by law. Changes to otice: We are required by law to maintain the privacy of your health information and to provide to you this otice of our Privacy Practices. We are required to practice the policies and procedures described in this notice, but we do reserve the right to change the terms of our otice. If we change our privacy practices we will be sure all of our patients receive a copy of the revised otice. Patient ame: Patient Acknowledgment: Patient/Guardian Signature: Date: / / 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 or to have us communicate with you by alternative means or at alternative locations, you may send a written complaint to our office or to the U.S. Department of Health and Human Services, Office of Civil Rights. We will not retaliate against you for filing a complaint.