PERSONAL HISTORY PRIVACY CONSENT

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1 PERSONAL HISTORY DATE PATIENT Title: Mr. Mrs. Miss Ms. Dr. Name Nickname Sex: Male Female Home Address Last First Middle Home Phone ( ) City & State Zip Code Social Security No. Age: Birth Employer Occupation Work Phone_ ( ) Employer s Address City Cell Phone ( ) School or Temporary Address address Preferred contact: Home Cell Active Military Yes No Are you a Full Time Student Yes No Where INSURED, PARENT or SPOUSE Self Parent Spouse Other _ Name Sex Male Female Home Address Home Phone ( ) City & State Zip Code Social Security No. Age: Birth Employer Occupation Employer s Address City Work Phone address Cell Phone ( ( ) ) Emergency Contact Telephone Physician s Name & Address Dentist s Name & Address If your account has an overpayment, whom do we send a refund? PRIVACY CONSENT Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The patient understands that: Protected health information may be disclosed or used for treatment, payment or health care options. The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review the Notice. The Practice reserves the right to change the Notice of Privacy Policies. The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions. The patient may revoke this Consent in writing at any time and all future disclosures will then cease. The Practice may condition treatment upon the execution of this Consent. Responsible Party Signature: ( ) : For Office Use ONLY X I R

2 Health History Patient name: : FIRST NAME LAST NAME Age: Height: Weight: What is your main problem: _? How long has it troubled you? Are you under a physician s care now? Yes/ No. For what? What major operations have you had? What prescription medications are you taking? (Include inhalers, oral contraceptives) Are you taking any herbal or natural remedies/vitamins/non-prescription drugs/diet pills? Are you or have you ever taken Bisphosphonates for osteoporosis or chemotherapy for multiple myeloma or other cancers (Reclast, Fosamax, Actonal, Boniva, Aredia, Zometa, Prolia). Yes/ No What medications are you allergic to? Are you allergic to any foods? Are you allergic to latex? Yes/ No Have you ever had any adverse effects from dental treatment? Yes/ No If yes, what was it? Have you had, or do you currently have: Heart disease Yes No Other Yes No Yes No Chest pain/angina Gallbladder trouble Neurologic disease Palpations/irregular heart beat GERD/IBS/stomach ulcers/ Crohn s disease/hyperacidity Mental health problems/ anxiety/depression High blood pressure Kidney disease/on dialysis Dizziness/fainting Heart surgery/stents Epilepsy/convulsions Artificial heart valves Osteoporosis/osteopenia Endocrine disease Coronary artery disease Tumor/cancer Treatment Diabetes Shortness of breath after mild Radiation treatment to head, Thyroid problems exercise neck, jaws Do your ankles swell Swollen neck glands TMJ/Jaw Chest pain on exertion Sinus disease/hay fever Clicking/popping Heart attack/ Stroke Snoring/sleep apnea Pain near ear Damaged heart valves/mitral CPAP/sleep appliance Difficulty opening mouth valve prolapse/heart murmur Rheumatic fever/heart disease Eye disease/glaucoma Grind or clench teeth Pacemaker/defibrillator Wear a night guard High cholesterol Are you on a diet Infectious disease Congenital heart disease Recurrent infections Blood disorders Do you chew tobacco? Hepatitis/liver disease Anemia Do you smoke? How many packs a day? Problems with immune system Bleeding/platelet disorder History of drug/ alcohol abuse HIV/AIDS Blood transfusion Participate in a treatment program Frequent/recurring mouth sores Hemophilia Bruise easily Lung disease Osteonecrosis Are you Pregnant? Severe/chronic coughing that produces blood Do you wish to have a pregnancy test? COPD/emphysema Removable dental appliance Are you trying to get pregnant? Bronchitis/pneumonia Artificial joint replacement (Knee, hip, shoulder) Are you taking oral contraceptives Tuberculosis Arthritis/swollen joints Are you nursing? Asthma/Difficulty Breathing *If you are using oral contraceptives it is important that you understand that antibiotics and other medication may interfere with the effectiveness of oral contraceptives. If you are pregnant or trying to become pregnant, surgery, anesthetics or any other medication may significantly harm your developing baby, especially during the first trimester. Do you want to talk privately with the Doctor about anything? Yes/ No Is there any additional information that you think the Doctor needs to know about?. Patient Signature (Guardian if patient is a minor) : Summary (Dr Use)

3 Contractual Agreement of CLINTON W. HOWARD, D.M.D., M.S. RICHARD P. BOYLE, D.D.S. JAMES E. VANGILDER, D.D.S. PATIENT S STATEMENT OF RESPONSIBILITY (Effective May 1, 2008) I understand that I am responsible to NRV Oral & Maxillofacial Surgery, LTD and their associates for payment of services rendered and that assignment of insurance benefits or filing of claims by this office does not in any way relieve me of final responsibility for settlement of my account(s). Where this agreement is executed by a spouse or a financial guarantor, they shall be jointly and severally liable with the patient, and do hereby promise and agree to pay NRV Oral & Maxillofacial, LTD., any and all amounts due and owing for the patient s account. Unless this office is specifically contracted with my insurance company and benefits have been verified for the recommended services, fees are due and payable at the time of service. I understand that verification of insurance benefits and network participation is solely my responsibility and not that of this office. If this practice is not specifically contracted with my insurance company, I understand that I am liable for all fees for services in full on the day of service and that by proceeding with treatment by a non-network provider with some insurance companies will result in lower payments or claim denial. I understand that this office will file my primary insurance only/secondary insurance will only be filed if the office is contracted with the company. I understand failure to provide adequate information, including insurance name, address, phone number, policy and group numbers at my initial visit or failure to update this office of new insurance, may result in reduced benefits. If my insurance company requires a referral and/or preauthorization, I understand that I am responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result in a lower insurance payment. I understand that I am expected to pay the balance of my account after my insurance company has paid or if more than 30 days have passed since my insurance claim was filed. Execution of this agreement also authorizes this office to file a complaint with the Insurance Commissioner as necessary on my behalf. I understand that general and local anesthesia may not be covered by my insurance and that a charge may be added to my account for missed appointments. NO GUARANTEE: I am aware that the practice of medicine is not an exact science, and I acknowledge that no guarantees have been made as to the result of any procedures, treatments, or examinations. I understand there will be a $25 service charge for all returned checks. If paid in full or any similar wording or other endorsement is indicated on my payment check, and the check is accepted by this office, I understand that I am still responsible for any remaining balance. Distribution of payment to my account(s) is the sole discretion of this office. Payments must be in US dollars and drawn on a United States financial institution or the United States Postal Service. DEFAULT Any breach or violation of this Agreement gives this office the right to exercise all other rights and remedies as provided by law. I agree, that in such event, I am obligated to pay reasonable collection expenses which may include but not limited to, court costs, collection fees which are charged by a collection agency up to 30% of the balance owed, and any applicable attorney s fees. I further agree that all collection fees as mentioned herein shall not be deemed to be in the nature of a penalty for default, but instead shall be deemed to be liquidated damages. I authorize payment of insurance benefits to NRV Oral & Maxillofacial Surgery, LTD., and the release of any medical information necessary to process the claim. In the event that my insurance policy prohibits direct payment to providers, this agreement shall serve as authorization for my insurance company to mail any payment in the form of a check in my name to the address of NRV Oral & Maxillofacial Surgery, LTD. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This agreement also authorizes this practice to deposit checks received on Patient s account when made to the patient or insured. HIV Testing My signature indicates that I have been informed that Virginia Law permits physicians to test patients or employees for HIV if anyone is exposed to their body fluids. A photocopy of this agreement shall be considered as effective and valid as the original. Patient s Name (PRINTED) Responsible Party Signature (Patient if 18 and older) Responsible Party SS# Witness

4 Consent For Use & Disclosure Of Protected Health Information For Treatment, Payment, or Health Care Operations I understand that as part of my healthcare, NRV Oral & Maxillofacial Surgery, LTD. prepares and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care and treatment. I also understand this health record serves as: A basis for planning my care & treatment A means of communication among the many health professionals who contribute to my care A source of information for obtaining my diagnosis and surgical information to prepare my bill A tool for assessing quality and reviewing the competence of health professionals My signature indicates that I have been provided with a Notice of Privacy Practices that provides a more complete description of my Protected Health Information (PHI) uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that NRV Oral & Maxillofacial Surgery, LTD. reserves the right to change its Notice of Privacy Practices and will notify me of any significant changes. I also understand that I have the right to restrict as to how my PHI may be used or disclosed to carry out treatment, payment or healthcare operations but that NRV Oral & Maxillofacial Surgery, LTD. is not required to accept the restrictions requested. With this consent, NRV Oral & Maxillofacial Surgery, LTD. may mail to my home or other designated location any items that assist the practice in carrying out treatment, payment or healthcare operations such as appointment reminder cards and patient statements. With this consent, NRV Oral & Maxillofacial Surgery, LTD. may to me appointment reminders and patient statements. Furthermore, NRV Oral & Maxillofacial Surgery, LTD. may reply (including PHI) to any signed by me as if it were a private telephone conversation. addresses not containing the patient s name must be verified by the patient prior to transmission. With this consent, NRV Oral & Maxillofacial Surgery, LTD. may call my home, work and other locations provided by me and leave a message (either in person or on voice mail) requesting me to call during office hours. I consent to NRV Oral & Maxillofacial Surgery, LTD. calling my home or cellular phone to leave messages, which may include my PHI including test results, appointment reminders, insurance requests and other issues related to my clinical care. By signing this form, I am authorizing NRV Oral & Maxillofacial Surgery, LTD. to use and disclose my PHI for the purposes of treatment, payment and healthcare operations. I acknowledge that I may revoke my consent for this use in writing (except as to the extent that the practice has already made disclosures) at any time. I further understand that if I do not provide this consent, NRV Oral & Maxillofacial Surgery, LTD. may refuse to provide treatment to me. Signature of Patient or Legal Guardian OVER

5 Print Patient Name NRV Oral & Maxillofacial Surgery, LTD. Permission to Discuss Protected Health Information Patient Name Patient Chart Number Please list anyone you give permission to receive information from NRV Oral & Maxillofacial Surgery, LTD. regarding your care and treatment including (but not limited to) medical diagnosis, prognosis, test results, and billing to the following: (This would include spouse, children, parents, etc) Name Relationship Signature of Patient or Legal Guardian