Bernard W Lynch, DMD, FAGD Dental Care Burke 703.596.1555 9239 Old Keene Mill Rad Burke VA 22015 NEW PATIENT INFORMATION Patient Name: Date: Please answer the fllwing cmpletely and thrughly: 1. What specifically happened that prmpted yu t call Dr. Lynch? 2. What are yur expectatins fr tday s appintment? 3. If yu have a dental prblem, what is the ne thing yu hate mst abut yur dental prblem? 4. What wuld yu like t hear during yur cnsultatin visit with Dr. Lynch? 5. When d yu want t start yur care? 6. What is the mst imprtant imprvement yu d like t see nce yur dental treatment with Dr. Lynch is cmplete? 7. What d yu feel is yur main dental prblem? What d yu feel is wrng? Hw lng have yu suffered?
8. Rate hw much yur dental prblem affects yu in each f the fllwing areas, 1 = n affect - 10 = affects me very much: Pain: Embarrassment: Eating difficulty: Willingness t Smile: 9. Please list everything yu ve dne t try t handle the prblem that hasn t wrked: 10. Why d yu feel that right nw is the time t fix yur dental prblems? 11. Hw are yur dental prblems affecting yur everyday life? 12. Please tell us abut any past dental experiences that were upsetting t yu? 13. What Imprvements wuld yu make in the appearance f yur teeth? And why? 14. S let s say we find smething. D yu prefer t save yur teeth? 15. Is there anything that wuld stand in yur way f getting the prper dentistry yu need? Fr example health, wrk, schl, finances. 16. D yu have any questins fr me?
MEDICAL HISTORY INFORMATION Name Date - - Date f Last Dental Visit: - - Reasn fr this Visit: Have yu ever had any f the fllwing? Please check thse that apply: AIDS/HIV Acid Reflux Anemia Arthritis/Rheumat ism Artificial Jints Artificial Heart Valves Asthma Back r Neck Prblems Bleeding Prblems Cancer/Tumrs Chest Pain Chemtherapy Chrnic Headaches Diabetes Type I Type II Dizziness/Fainting Epilepsy Emphysema Glaucma Hay fever Head injuries Heart disease Heart murmur/mvp Hepatitis A, B, C High/Lw Bld Pressure Jaundice Jaw Prblems Kidney Disease Liver Disease Leukemia Mental Disrders Neck Prblems Nervus Disrders Oral Herpes Pacemaker Pregnancy Due Date: Radiatin Treatment Respiratry Prblems Rheumatic Fever Shingles Sinus prblems Stmach Prblems Strke/Heart Attack Thyrid Prblems Tuberculsis (TB) Ulcers Sexually Transmitted Disease (STDs) ALLERGIES Cdeine Allergy Penicillin Allergy Sulfa Allergy Aspirin Allergy Tetracycline Allergy Latex Allergy Envirnmental Allergies Other Allergies: Other Cnditins Nt Listed: Are yu in general gd health at this time? Yes N If yes, please rate frm 1(best) -10 (wrst): Have yu ever had any cmplicatins fllwing dental treatment? Yes N If yes, please explain: D yu use tbacc? Yes N Hw much? Hw lng? Type? Have yu ever had an allergic reactin t Nvcaine anesthetic? Yes N If yes, any reactins r allergic symptms, please explain: D yu have a histry f Peridntal (gum) Disease? Yes N Have yu been admitted t a hspital r needed emergency care during the past tw years? Yes N If yes, please explain: Are yu nw under the care f a physician? Yes N Are yu taking medicatin? Yes N If Yes, Please list ALL (Herbs, Vitamins, Aspirin) List: Name f Physician: Phne: - - Please explain if yu have any health prblems that need further clarificatin? T the best f my knwledge, all f the preceding answers and infrmatin prvided are true and crrect. If I ever have any change in my health, I will infrm the dctrs at the next appintment withut fail. Date: Signature f patient, parent r guardian
Patient Infrmatin Patient Name: Date: Last First MI Male Female Married Single Child Other Scial Security #: _- - Birth Date: - - DL# Issuing State Phne (Hme): (Wrk): Ext: Cell Phne: Email address: May we cntact yu by email? Yes N Address: Street City State Zip Cde Referral Infrmatin Whm may we thank fr referring yu t ur practice? Anther patient Brchure Dental Office Previus Practice Website Other Name f persn r ffice referring yu t ur practice: Emplyment Infrmatin The fllwing is fr: the patient the persn respnsible fr payment Emplyer Name: Occupatin: Address: Street City State Zip Cde Insurance Infrmatin We will assist in yur insurance prcessing Name f Insured: is insured a patient? Yes N Last First MI Insured's Birth Date: ID #: Grup #: Scial Security #: Insured's Address: Street City State Zip Cde Insured's Emplyer Name: Address: Street City State Zip Cde Patient's relatinship t insured: Self Spuse Child Other Insurance Plan Name and Address: If yu have dental insurance, we will help yu receive the maximum benefits frm yur plicy. As a curtesy t yu, we will cmplete a claim frm and send it t yur insurance cmpany. Yu can be reimbursed by yur insurance cmpany t yur hme r have the reimbursement received at the ffice fr future treatment credit. Cnsent fr Services Payment fr dental treatment is due at the time service is rendered. In additin t cash and checks, we accept mst majr credit cards and Care Credit. I grant my permissin t yu r yur assignee, t telephne me at hme r at my wrk t discuss matters related t this frm. I have read the abve cnditins f treatment and payment and agree t their cntent. Date: Relatinship t Patient: Signature f patient, parent r guardian Date: Relatinship t Patient: Signature f guarantr f payment/respnsible party
DENTAL CARE BURKE NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO 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 11-01- 05, 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 law permits such changes. 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 are nt affiliated with any insurance cmpanies and d request payment at the time f service. Financial Arrangements can be discussed with ur Business Team. A mnthly service charge f 3% will be added t accunts 30 days past due. 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, YOU 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 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 the payment f 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 insist 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 reject 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 the 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 authrize 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 vicemail messages, pst cards, 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, there will be a charge f $55.00 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 yu a cst-based fee fr prviding yur health infrmatin in that frmat. If yu prefer, we will prvide 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 n which ur business assciates r we 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, 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 specify the alternative means r lcatin, and prvide satisfactry explanatin f 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 (e-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 alternative 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. Cntact: Dental Care Burke Telephne: 703-596-1555 Fax: 703-543-0327 E-mail: inf@dentalcareburke.cm Address: 9239 Old Keene Mill Rad Burke VA 22015
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES **Yu May Refuse t Sign This Acknwledgement** I,, have received a cpy f this Office s Ntice f Privacy Practices. {Please Print Name} {Signature} {Date} 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 failed t sign Cmmunicatins barriers prhibited btaining the acknwledgement An emergency situatin prevented us frm btaining acknwledgement Other (please specify) 2002 American Dental Assciatin All Rights Reserved Reprductin and use f this frm by dentists and their staff is permitted. Any ther use, duplicatin r distributin f this frm by any ther party requires the prir written apprval f the American Dental Assciatin. This Frm is educatinal nly, des nt cnstitute legal advice, and cvers nly federal, nt state, law (August 14 2002).