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Microsoft word - drs b and g new patient packet 20080212 version.doc

PATIENT REGISTRATION AND MEDICAL HISTORY
Patient_______________________________________________________________________ Street Address_______________________________City_____________State_____Zip______ Home Phone (___)_____-_______E-Mail____________________________________________ DOB___/___/___SS#____-____-____Marital Status_______ Spouse/Partner_______________ Employer_______________________________________ Work Phone (____)_____-________ Occupation______________________________________ Cell Phone (____) _____-________ Name of Dental Insurance Company________________________________________________ Name of Subscriber________________________ Subscriber Number _____________________ Who is responsible for this account? _________________ Relation to patient________________ In case of an emergency, who should be notified? ______________________________________ Home Phone (____) _____-______ Other Phone (____) _____-______ Who can we thank for referring you to our office?_____________________________________ DENTAL HISTORY
Why have you come to the dentist today?___________________________________________ My last dental cleaning was_____/_____/_____My last dental exam was_____/_____/_____ Have you ever had to pre-medicate before Have you ever had a serious/difficult problem associated with dental work? Do you smoke or use tobacco in any other form? † † Do you now or did you ever clench or grind your teeth? Do you now or have you ever experienced pain/discomfort in your jaw (TMJ)? Is there any other significant dental history that we should know about? If yes, please explain_____________________________________________ On a scale of 1-10 how would you rate What would you do specifically to make your smile a 10? _____________________________ -Continued on Back-
MEDICAL HISTORY
Name of physician:______________________ Phone#: (____)_____-_____Date of last visit:___/___/____ Have you ever been hospitalized? If yes, please explai n__________________________________________
In order to care for you to the best of our abilities, please answer the following.
Congenital Heart Disease, Heart Disease, Heart Attack, Angina Arthritis, Back Pain, Multiple Sclerosis, etc † Cognitive or Intellectual Impairments ALLERGIES/REACTIONS
Other_________________________________________
MEDICATIONS
Please list any prescription or over the counter medications you are taking at this time. Do you have any disease, condition or problem not listed above that you think we should know about? If yes, please explain. _________________________________________________________________________________ I UNDERSTAND that the information that I have given today is correct to the best of my knowledge. I also
understand that this information will be held in the strictest confidence and it is my responsibility to inform this
office of any changes in my medical status.
Signature________________________________________________Date____________________
(If under 18, Parent or Guardian signature required.) Drs Bankhead and Groipen DDS PC
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND 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 to maintain the privacy of your health information. We are also
required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health
information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice
takes effect 04/14/2003, and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice. USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:
Treatment: We may use or disclose your health information to a physician or other healthcare provider providing
treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare
operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence
or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training
programs, accreditation, certification, licensing or credentialing activities.
Your Authorization: In addition to our use of your health information for treatment, payment or healthcare
operations, you may give us written authorization to use your health information or to disclose it to anyone for any
purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any
use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization,
we cannot use or disclose your health information for any reason except those described in this Notice.
To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights
section of this Notice. We may disclose your health information to a family member, friend or other person to the
extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may
do so.
Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of
(including identifying or locating) a family member, your personal representative or another person responsible for
your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your
health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your
incapacity or emergency circumstances, we will disclose health information based on a determination using our
professional judgment disclosing only health information that is directly relevant to the person’s involvement in your
healthcare. We will also use our professional judgment and our experience with common practice to make
reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-
rays, or other similar forms of health information.
Marketing Health-Related Services: We will not use your health information for marketing communications without
your written authorization.
Required by Law: We may use or disclose your health information when we are required to do so by law.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that
you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may
disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health
or safety of others.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under
certain circumstances. We may disclose to authorized federal officials health information required for lawful
intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or
law enforcement official having lawful custody of protected health information of inmate or patient under certain
circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with appointment
reminders (such as voicemail messages, postcards, or letters).
PATIENT RIGHTS
Access:
You have the right to look at or get copies of your health information, with limited exceptions. You may
request that we provide copies in a format other than photocopies. We will use the format you request unless we
cannot practicably do so. You must make a request in writing to obtain access to your health information.
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates
disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain
other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a
12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your
health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our
agreement (except in an emergency).
Alternative Communication: You have the right to request that we communicate with you about your health
information by alternative means or to alternative locations. {You must make your request in writing.} Your
request must specify the alternative means or location, and provide satisfactory explanation how payments will be
handled under the alternative means or location you request.
Amendment: You have the right to request that we amend your health information. (Your request must be in
writing, and it must explain why the information should be amended.) We may deny your request under certain
circumstances.
Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to
receive this Notice in written form upon request.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us.
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. Contact Officer: David Chapman Telephone: 1-617-364-5500 Fax: 1-617-361-1351 E-mail: Privacy@bankheadandgroipen.com Address: 1259 HydePark Ave, Hyde Park, MA 02136 Drs Bankhead and Groipen DDS PC
ACKNOWLEDGEMENT
OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES
**You May Refuse to Sign This Acknowledgement**
, have received a copy of this office’s Notice of 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: Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Patient Name:__________________________________________________________________
Consent To Treatment
I consent to treatment as necessary or desirable to the care of the patient first named above, including but not restricted to whatever drugs, medicine, performance of operations and conduct of laboratory, x-ray or other studies that may be used by the attending doctor, or his nurse or Signature_____________________________________Date______________________
(If under 18, Parent or Guardian signature required.) Financial Policy
Payment and deductibles are due at the time of service. Payment can be made with the following options: C. Major credit card (Mastercard, Visa, American Express, Discover) a. Including flexible spending plan cards
Signature_____________________________________Date______________________

(If under 18, Parent or Guardian signature required.)
Cancellation Policy

We will make every effort to schedule your appointments to accommodate your needs. If you are unable to keep your appointment, please notify us as soon as possible. This courtesy makes it possible to give the appointment to another patient. If you do not cancel within 24 hours, a cancellation fee will be applied to your account.

Signature
_____________________________________Date______________________
(If under 18, Parent or Guardian signature required.) *Please speak with our financial department for details on CareCredit.

Source: http://www.adrianrodriguez.ws/BG/docs/newPatient.pdf

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