PERSONAL. Guarantor Name Last First MI (Preferred)
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1 PATIENT INFORMATION We are pleased t welcme yu t ur ffice. Please take a few minutes t fill ut this frm as cmpletely as yu can. If yu have any questins we ll be glad t help yu. PERSONAL Patient Name Last First MI (Preferred) Birthdate SS# DL# Gender: M F Married: Y N Hme Phne Cell Phne Address Address 2 City State Zip Hw did yu hear abut us? (Please be specific s we can thank them!) If patient is under 18 yrs, please als cmplete the fllwing: Guarantr Name Last First MI (Preferred) Birthdate SS# DL# Gender: M F Married: Y N Wrk Phne Cell Phne Student status if dependent ver 19 (fr ins) Nnstudent Fulltime Part time INSURANCE POLICY 1 Patient relatinship t subscriber: Self Spuse Child Subscriber Name Sub.ID # Sub.DOB Insurance Cmpany Phne Emplyer Grup Name Grup # INSURANCE POLICY 2 Patient relatinship t subscriber: Self Spuse Child Subscriber Name Sub.ID # Sub.DOB Insurance Cmpany Phne Emplyer Grup Name Grup # FINANCIAL AGREEMENT * Fr my cnvenience, this ffice may release my infrmatin t my insurance, and receive payment directly frm them. * If sent t cllectins, I agree t pay a $30 cllectin fee, all related fees and curt csts. * Every effrt will be made t help me with my insurance, but if they d nt pay as expected, I will still be respnsible. * Treatment plans may change, and I will be respnsible fr the wrk actually dne. Signature
2 MEDICAL HISTORY Name f Medical Dctr: City/State Emergency Cntact Phne Relatinship List all the medicatins r drugs yu are nw taking: Check medicatins r drugs yu are allergic t: [ ] Nne Nne Lcal Anesthetics Aspirin Metals Cdeine/ Other Narctics Penicillin Erythrmycin Sulfa Drugs Latex Rubber Other: Check any medical cnditins yu may have: Nne Diabetes Jint Replacement, f: AIDS/HIV Emphysema Kidney/Bladder Truble Alchl/Drug Abuse Epilepsy Liver Disease Anemia/Leukemia Fainting Spells/Seizures Lw Bld Pressure Anrexia/Bulimia Fever Blisters/Herpes Mental Health Prblems Arthritis Frequent Headaches Mitral Valve Prlapse Asthma/Hay Fever Frequently Dry Muth/Sjgren Persistent Diarrhea Bld Cltting Prblems Gall Bladder Truble Rheumatic Fever Bld Transfusin Heart Attack/Strke Rheumatic Heart Disease Brnchitis Heart Disease/Angina Sexually Transmitted Disease Cancer/Tumr r Grwth Heart Murmur Sinus Truble Cardiac Pacemaker Hepatitis/Jaundice Stmach Ulcers Chest Pain Upn Exertin High Bld Pressure Thyrid Prblems Damage Heart Valve Hives/Skin Rash Tuberculsis Other: WOMEN ONLY- Are yu pregnant r d yu have reasn t believe yu may be? Yes / N Tbacc use? If s, what kind and hw much? Unusual reactin t dental injectins? Reasn fr tday s visit: Are yu in pain? Yes / N New patients: Name f frmer dentist City/State f last cleaning and exam By signing belw, I certify that all f the abve infrmatin is true t the best f my knwledge. Patient/Guardian Name (Printed) Patient/Guardian Signature Dctr Signature
3 NOTICE OF PRIVACY PRACTICES This ntice describes hw health infrmatin abut yu may be used and disclsed and hw yu can get access t this infrmatin. Please review it carefully. The privacy f yur health is imprtant t us. OUR LEGAL DUTY We are required by applicable federal and state law t maintain the privacy f yur health infrmatin. We are als required t give yu this Ntice abut ur privacy practices, ur legal duties, and yur rights cncerning yur health infrmatin. We must fllw the privacy practices that are described in this Ntice while it is In effect. This Ntice takes effect (10/13/03), and will remain in effect until we replace it. We reserve the right t change ur privacy practices and the terms f this Ntice at any time, prvided such changes are permitted by applicable law. We reserve the right t make the changes in ur privacy practices and the new terms f ur Ntice effective fr all health infrmatin that we maintain, including health infrmatin we created r received befre we made the changes. Befre we make a significant change in ur privacy practices, we will change this Ntice and make the new Ntice available upn request. Yu may request a cpy f ur Ntice at any time. Fr mre infrmatin abut ur privacy practices, r fr additinal cpies f this Ntice, please cntact us using the infrmatin listed at the end f this Ntice. USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclse health infrmatin abut yu fr treatment, payment, and healthcare peratins. Fr example: Treatment: We may use r disclse yur health infrmatin t a physician r ther healthcare prvider prviding treatment t yu. Payment: We may use and disclse yur health infrmatin t btain payment fr services we prvide t yu. Healthcare Operatins: We may use and disclse yur health infrmatin in cnnectin with ur healthcare peratins. Healthcare peratins include quality assessment and imprvement activities, reviewing the cmpetence r qualificatins f healthcare prfessinals, evaluating practitiner and prvider perfrmance, cnducting training prgrams, accreditatin, certificatin, licensing r credentialing activities. Yur Authrizatin: In additin t ur use f yur health infrmatin fr treatment, payment r healthcare peratins, yu may give us written authrizatin t use yur health infrmatin r t disclse it t anyne fr any purpse. If yu give us an authrizatin, yu may revke it in writing at any time. Yur revcatin will nt affect any use r disclsures permitted by yur authrizatin while it was in effect. Unless yu give us a written authrizatin, we cannt use r disclse yur health infrmatin fr any reasn except thse described in this Ntice. T Yur Family and Friends: We must disclse yur health infrmatin t yu, as described in the Patient Rights sectin f this Ntice. We may disclse yur health infrmatin t a family member, friend r ther persn t the extent necessary t help with yur healthcare r with payment fr yur healthcare, but nly if yu agree that we may d s. Persns Invlved In Care: We may use r disclse health infrmatin t ntify, r assist in the ntificatin f (including identifying r lcating) a family member, yur persnal representative r anther persn respnsible fr yur care, f yur lcatin, yur general cnditin, r death. If yu are present, then prir t use r disclsure f yur health infrmatin, we will prvide yu with an pprtunity t bject t such uses r disclsures. In the event f yur incapacity r emergency circumstances, we will disclse health infrmatin based n a determinatin using ur prfessinal judgment disclsing nly health infrmatin that is directly relevant t the persn's invlvement in yur healthcare. We will als use ur prfessinal judgment and ur experience with cmmn practice t make reasnable inferences f yur best interest in allwing a persn t pick up filled prescriptins, medical supplies, x-rays, r ther similar frms f health infrmatin. Marketing Health-Related Services: We will nt use yur health infrmatin fr marketing cmmunicatins withut yur written authrizatin. Required by Law: We may use r disclse yur health infrmatin when we are required t d s by law. Abuse r Neglect: We may disclse yur health infrmatin t apprpriate authrities if we reasnably believe that yu are a pssible victim f abuse, neglect, r dmestic vilence r the pssible victim f ther crimes. We may disclse yur health infrmatin t the extent necessary t avert a serius threat t yur health r safety r the health r safety f thers.
4 Natinal Security: We may disclse t military authrities the health infrmatin f Armed Frces persnnel under certain circumstances. We may disclse t authrized federal fficials health infrmatin required fr lawful intelligence, cunterintelligence, and ther natinal security activities. We may disclse t crrectinal institutin r law enfrcement fficial having lawful custdy f prtected health infrmatin f inmate r patient under certain circumstances. Appintment Reminders: We may use r disclse yur health infrmatin t prvide yu with appintment reminders (such as vic messages, pstcards, r letters). PATIENT RIGHTS Access: Yu have the right t lk at r get cpies f yur health infrmatin, with limited exceptins. Yu may request that we prvide cpies in a frmat ther than phtcpies. We will use the frmat yu request unless we cannt practicably d s. (Yu must make a request in writing t btain access t yur health infrmatin. Yu may btain a frm t request access by using the cntact infrmatin listed at the end f this Ntice. We will charge yu a reasnable cst-based fee fr expenses such as cpies and staff time. Yu may als request access by sending us a letter t the address at the end f this Ntice. If yu request cpies, we will charge yu $2.00 fr each page, $15.00 per hur fr staff time t lcate and cpy yur health infrmatin, and pstage if yu want the cpies mailed t yu. If yu request an alternative frmat, we will charge a cst-based fee fr prviding yur health infrmatin in that frmat. If yu prefer, we will prepare a summary r an explanatin f yur health infrmatin fr a fee. Cntact us using the infrmatin listed at the end f this Ntice fr a full explanatin f ur fee structure.) Disclsure Accunting: Yu have the right t receive a list f instances in which we r ur business assciates disclsed yur health infrmatin fr purpses, ther than treatment, payment, healthcare peratins and certain ther activities, fr the last 6 years, but nt befre April 14, If yu request this accunting mre than nce in a 12-mnth perid, we may charge yu a reasnable, cst-based fee fr respnding t these additinal requests. Restrictin: Yu have the right t request that we place additinal restrictins n ur use r disclsure f yur health infrmatin. We are nt required t agree t these additinal restrictins, but if we d, we will abide by ur agreement (except in an emergency). Alternative Cmmunicatin: Yu have the right t request that we cmmunicate with yu abut yur health infrmatin by alternative means r t alterative lcatins. {Yu must make yur request in writing.} Yur request must specify the alternative means r lcatin, and prvide satisfactry explanatin hw payments will be handled under the alternative means r lcatin yu request. Amendment: Yu have the right t request that we amend yur health infrmatin. (Yur request must be in writing, and it must explain why the infrmatin shuld be amended.) We may deny yur request under certain circumstances. Electrnic Ntice: If yu receive this Ntice n ur Web site r by electrnic mail ( ), yu are entitled t receive this Ntice in written frm. QUESTIONS AND COMPLAINTS If yu want mre infrmatin abut ur privacy practices r have questins r cncerns, please cntact us. If yu are cncerned that we may have vilated yur privacy rights, r yu disagree with a decisin we made abut access t yur health infrmatin r in respnse t a request yu made t amend r restrict the use r disclsure f yur health infrmatin r t have us cmmunicate with yu by alterative means r at alternative lcatins, yu may cmplain t us using the cntact infrmatin listed at the end f this Ntice. Yu als may submit a written cmplaint t the U.S. Department f Health and Human Services. We will prvide yu with the address t file yur cmplaint with the U.S. Department f Health and Human Services upn request. We supprt yur right t the privacy f yur health infrmatin. We will nt retaliate in any way if yu chse t file a cmplaint with us r with the U.S. Department f Health and Human Services.
5 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES ** Yu May Refuse t Sign This Acknwledgement ** I,, have received a cpy f this ffice's Ntice f Privacy Practices. Name f Patient (r parent if under 18 years) Patient Name (printed) Signature f Patient (r parent if under 18 years) Fr Office Use Only We attempted t btain written acknwledgement f receipt f ur Ntice f Privacy Practices, But acknwledgement culd nt be btained because: Individual refused t sign Cmmunicatin barriers prhibited btaining the acknwledgement An emergency situatin prevented us frm btaining acknwledgement Other (Please Specify) Emplyee Signature
JOHN L. LITTLE, D.D.S, P.A ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES. May Refuse to Sign This Acknowledgement-
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