EXAMINATION Date..._. Patient's name. Address:......_..... Telephne: Hme Nickname _......._........ Business.......... Business _....... Patient emplyed by. ~......._... Psitin._..._. Psitin held hw lng........._ Date f birth.. Persn respnsible fr payment f this accunt..... Wh referred yu t ur ffice?... INITIAL REQUEST: TELEPHONE CONVERSATION: --_._---_... -----_.._--_..._---..._-_... _--- HEALTH HISTORY Name f fam ily physician ~....................._...._ When was yur last physical examinatin?...._..._..._~ Have yu been under the care f a medical elctr within the last year? _~..._.._.~. ~~_ If s, fr what reasn?........ Are yu nw taking an" drugs r medicatins?._... Fr what reasn?....._.. Have yu ever had excessive bleeding frm a cut r tth extractin?........._........ Are yu allergic t penicillin r any ther medicatin?..............._...._ ~._ Is there any pain medicine that makes yu sick r drwsy? _~......._..._.... D yu sm1(e cigarettes?.. Hw many packs a day? D yu frequently feel "run dwn" r have a slight fever?.._. D yu ften have headaches? Any particular time f day?...... ~._. ~~... ~ (Wmen) Are yu nw pregnant? _..._.... _ Hw many mnths?........._.... Have yu ever had any f the fllwing? (Please circle) Rheumatic fever Diabetes Anemia r bld disease Tuberculsis Arthritis Heart disease Cancer Radiatin treatments Hepatitis High bld pressure Signature:.... DENTAL HISTORY Why did yu seek dental care at this time? ------_..._--_..._..._... -- Are yu satisfied with past dental treatment? D yu want t keep yur teeth as lng as yu can?... ~..............._ Are yu ever aware f grinding r clenching yur teeth?...._ Are yu ever trubled with "bad breath"].._._. ~ ~_...._..... Are yu satisfied with the appeerance f yur teeth?............... Has the fear f discmfrt kept yu frm regular dental care? Hw d yu feel abut yur teeth? -------------..._--_.------------- --------
Patient Infrmatin and Healrh Histry NAME DATE DENTAL HISTORY DO YOU HAVE OR DO YOU USE ANY OF THE FOLLOWING PLEASE INDICATE WITH A (v') Teelh se:nsalive 10 cld, heat, sweels r pressure 8ad breath CigarGlles, pipe r cigar smking Bleeding gums. riow lng Unpieasant tsste Texture f tthbrush..~.... _.. _ CJ Fd impactin Unlavrable dentai experience Frequency 01 brushing ~_ O Clenchin):! r grinding Cmplicatins lrm e~tfactins DenIal Ilss B<;rnin\j t tngue Peridntal treatment [] Inler dental stimulatrs. 0 Swelling r lumps in muth Orthdntic treatment Water jel device Frequent!llisters n lips r mulh Muth bleed,ng Oiaclsing tablels r slutin Pain arund ear Ora! habit, I.e., nnge[nad biting, Fluride supplements Unusual sunds in ear while ealing cheek biting, etc Smkeless tbacc MEDICAL HISTORY Physician's Name, ~~ Date f Last Physical Exam. Age, DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING - INDICATE WITH A (v') [] Aliergles t drugs [J Aslhma [J Str~,e Allergies t anesh-,eucs Haylever r allergies in general (J Tnyrid Any heart aliments [] Diabe,es Eye disrders [] High bld pressure Kidney pr;81115 (J Tnsiliilus C] Neurlgical prblems [] Liver prblems r hepatitis [] TuberculOSIS ::1 RadIatin treatments Mairgnancies/cancer [] Ulcer r clius [] Excessive bleeding trm cut r extraclin [] Psychiatric r ",mtinal prblems Pregnancy [] Anemia r blood prblems [] Rheumatic lever II s, what mnth, ~ ArthritiS [] Sinus prblems [] Venereal disease C:! Artifica! iints Irnmurli" System DIsrder (HIV. AIDS, ARC) U Mylral valve prlapse Cr1em,cal dependent Birth cntrl pills [] Frequency f alchl use. C Surgeries [] Translusin/rec6ive bld [] Olher ~ Describe any current medical treatment, including drugs taken, even thugh nt listed abve I DATE UPDATED RECORD l I : I : : I
Charles Tucker, D.D.S. 515 Cllege Alva, OK 73717 580-327-2277 NOTICE OF PRIVACY PRACTICES This ntice is t infrm yu that yur persnal health infrmatin will nly be used fr purpses f treatment in ur facility and will nt be misused r disclsed by / t anyne utside f ur practice. Yu may gain access t this infrmatin if yu desire. Please review if carefully. The privacy f yur health infrmatin 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 f April 14,2003 and will remain in effect. 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 r 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 Disclsures f Health Infrmatin 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 wh is currently prviding treatment t yu. Payment: We may use and disclse yur health infrmatin t btain payment fr services we prvide t yu (i,e. insurance cmpanies). 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, yur 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 disclsure permitted by yur authrizatin while it was in effect. Unless yu give 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 it 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 (included 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 r yur health infrmatin, we will prvide yu with an pprtunity t bject t such uses f 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 that 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- Relatin Services: Our dental ffice des nt use patient infrmatin fr any marketing purpses. 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 it is required by law t d s (i.e. missing persn, etc,) 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. Natinal Security: We may disclse t military authrities the health infrmatin f Armed Frces persnnel under certain circumstances. We may disclse t lawfully authrized federal fficials health infrmatin required by lawful intelligence. cunterintelligence, and ther natinal security activities. We may disclse t crrectinal institutins r law enfrcement fficials 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 vicemail 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 may charge yu a reasnable cst-based fee fr expenses such as cpies and staff time, Yu may request access by sending us a letter t the address at the end f this ntice, If yu request n 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 n 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 infrmaiin fr any purpse. ther than treatment. payment, healthcare peratins and certain ther activities, fr the last 6 years. but nt befre April 14. 2003. 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 alternative lcatins. (Yu must make yur request in writing). Yur request must specity the alternative means r lcatins. 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. It must explain why the infrmatin shuld be amended). We may deny yur request under certain circumstances, Questins and Cmplaints: If yu desire further infrmatin abut ur privacy practices r if yu have questins, please cntact us. If yu are cncerned that we may have vilated yur privacy right. 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 alterclative 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 cmplain! with us r with the U.S, Deprtment f Health and Human Services. Cntact Officer: Dnna White, Privacy Officer Dr. Charles Tucker. Owner Telephne: 580-327-2277 Address: 515 Cllege Alva, OK 73717
Charles Tucker, D.D.S. 515 Cllege Alva, OK 73717 580-327 -2277 ACKNOWLEDGEMENT Of RECEIPT Of NOTICE Of PRIVACY PRACTICES Yu may refuse t sign this acknwledgement I have received a cpy f Dr. Charles Tucker's Ntice f Privacy Practices. Please Print Name Signature Date 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 Cmmunicatins barriers prhibited btaining the acknwledgement An emergency situatin prevented us frm btaining acknwledgement Other:
STUCKER, P.O. OX 388 515 AVE. i\lv 73717.S. BENEFlTS TO PHYSICIAN: YES NO p,lymems RELEASE YES NO f my bill nt cvered my I HEREBY AUTHORIZE RELEASE OF INfOIUv'lATJON FOR INSURANCE PUllPOSES ~ YES NO The foi- rtleilse lde,y induct". infrmatin, \vlllch rnay be cn~ldelcd " COITIl11llflical:,je r venereal HIV, ;.'1J AIDS. 1 understand all f [be abve and hereby Slme,hm lnfrrnatin is crrec, t,h<: besr f my