Acknowledgement of Receipt of Notice of Privacy Practices

Transcription

1 HIPAA PRIVACY FORM 2 Acknowledgement of Receipt of Notice of Privacy Practices Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to document our good faith effort to obtain that acknowledgement American Dental Association All Rights Reserved Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association. This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002). HIPAA PRIVACY FORMS 65

2 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. Please Print Name Signature Date For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify) 2002 American Dental Association All Rights Reserved Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association. This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).

3 Leslie A. Mitchell, DMD 440 Villa Rd. Newberg, OR (503) Policy on Broken Appointments Our office has a 24 hour cancellation policy. There is a $50.00 charge per scheduled appointment not kept. After 3 broken appointments or same day cancellations, you will be put on a Same day ONLY status. Signing this statement does not constitute agreement or disagreement with the policy described. Signing merely indicates you have been informed of our office policy regarding broken dental appointments. I HAVE READ AND UNDERSTAND THE ABOVE: Signature of patient or parent Date:

4 Dental Concerns Assessment Patient s Name Date Please rank your concerns or anxiety over the dental procedures listed below. Please fill in any additional concerns. Level of Concern 1. Anesthetic ( Novocaine ) 2. Radiographs ( X-Rays ). 3. Jaw getting tired Gag reflex 5. Fear of being injured 6. Not being in control or able to stop the dentist.. 7. The amount of treatment needed.. 8. Sounds and/or smells in the dental office. 9. Not feeling free to ask questions or to be listened to 10. Receiving too little information. 11. Too many short appointments or too long of appointments None Low Med. High Explain 12. Please rate your smile (Dislike it) (Love it) Do you require premedication or Nitrous Oxide with your dental care? Comments:

5 Let us keep the Sparkle in your Smile We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we ll be glad to help you. We look forward to working with you in maintaining your dental health. Patient Information Date Phone Alt. Phone Name SS/HIC/Patient ID # Last Name First Name Middle Initial Address City State Zip Sex M F Age Birthdate Married Widowed Single Minor Separated Divorced Partnered for Years Patient Employer/School Occupation Employer/School Address Employer/School Phone Whom may we thank for referring you? In case of emergency who should be notified? Phone Primary Insurance Person Responsible for Account Last Name First Name Middle Initial Relation to Patient Birthdate SS/HIC/Patient ID # Address (if different from patient) Phone City State Zip Person responsible employed by Occupation Business Address Business Phone Insurance Company Contract # Group # Subscriber # Names of other dependants covered under this plan Additional Insurance Is patient covered by additional insurance Subscriber name Relation to patient Birthdate Address (if different from patient) Phone City State Zip Subscriber employed by Business Phone Insurance Company Soc. Sec. # Contract # Group # Subscriber # Names of other dependants covered under this plan Please complete both sides

6 Dental History Reason for Today s Visit Date of Last Dental Care Former Dentist Date of last Dental x-rays Address Check ( ) if you have had any problems with any of the following: Bad breath Bleeding gums Clicking or popping jaw Food collection between Teeth Grinding teeth Loose teeth or broken fillings Periodontal treatment Sensitivity to cold Sensitivity to hot Sensitivity to sweets Sensitivity when biting Sores/growths in your mouth How often do you floss? How often do you brush? Medical History Physician s Name Date of Last Visit Have you ever used a bisphosphonate medication? Common brand names are Fosamaz, Actonel, Atelvia, Didronel, Boniva. Yes No Have you ever taken any of the group of drugs collectively referred to as fen-phen? These include combinations of Ionimin, Adipex, Feslin (brand names of phentermine) and Redux (dexfenfluramine). Yes No Have you had any serious illnesses or operations? Yes No if yes, describe Have you ever had a blood transfusion? Yes No if yes, give approximate date (Women) Are you pregnant? Yes No Nursing? Yes No Taking Birth Control Pills? Yes No Check ( ) if you have or have had any of the following: Anemia Arthritis, Rheumatism Artificial Heart Valves Artificial Joints Asthma Back Problems Blood Disease Cancer Chemical Dependency Chemotherapy Circulatory Problems Cortisone Treatments Cough, Persistent Cough up Blood Diabetes Epilepsy Fainting Glaucoma Headaches Heart Murmur Heart problems Hemophilia Hepatitis High Blood Pressure HIV/AIDS Jaw Pain Kidney Disease Liver Disease Mitral Valve Prolapse Pacemaker Radiation Treatment Respiratory Disease Rheumatic Fever Scarlet Fever Shortness of Breath Skin Rash Stroke Swelling of Feet/Ankles Thyroid Problems Tobacco Habit Tonsillitis Tuberculosis Ulcer Venereal Disease Medications: List medications you are currently taking: Allergies Authorization I certify that I and/or my dependent(s), have insurance coverage with and assign directly to dr. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named dentist may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for service and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. Signature of Patient, Parent, Guardian, or Persona Representative Date Print name of Patient, Parent, Guardian, or Persona Representative Date Payment is due in full at time of treatment unless prior arrangements have been approved.

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