The Health Insurance Portability & Accountability Act of 1996 (HIPAA) requires all health care records and other individually identifiable health information (protected health information) used or disclosed to us in any form, whether electronically, on paper, or orally, be kept confidential. This federal law gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information. As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. Without specific written authorization, we are permitted to use and disclose your health care records for the purposes of treatment, payment and health care operations. • Treatment means providing, coordinating, or managing health care and related services by
one or more health care providers. Examples of treatment would include crowns, fillings, teeth • Payment means such activities as obtaining reimbursement for services, confirming coverage,
billing or collection activities, and utilization review. An example of this would be billing your dental plan for your dental services.
Health Care Operations include the business aspects of running our practice, such as
conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would include a periodic assessment of our In addition, your confidential information may be used to remind you of an appointment (by phone or mail) or provide you with information about treatment options or other health-related services including release of information to friends and family members that are directly involved in your care or who assist in taking care of you. We will use and disclose your protected when we are required to do so by federal, state or local law. We may disclose your PROTECTED HEALTH INFORMATION to public health authorities that are authorized by law to collect information, to a health oversight agency for activities authorized by law included but not limited to: response to a court or administrative order, if you are involved in a lawsuit or similar proceeding, response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested. We will release your PROTECTED HEALTH INFORMATION if requested by a law enforcement official for any circumstance required by law. We may release your PROTECTED HEALTH INFORMATION to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs. We may release PROTECTED HEALTH INFORMATION to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor. We may use and disclose your PROTECTED HEALTH INFORMATION when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat. We may disclose your PROTECTED HEALTH INFORMATION if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities. We may disclose your PROTECTED HEALTH INFORMATION to federal officials for intelligence and national security activities authorized by law. We may disclose PROTECTED HEALTH INFORMATION to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations. We may disclose your PROTECTED HEALTH INFORMATION to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals or the public. We may release your PROTECTED HEALTH INFORMATION for workers' compensation and similar programs. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. You have certain rights in regards to your PROTECTED HEALTH INFORMATION, which you can exercise by presenting a written request to our Privacy Officer at the practice address listed below: • The right to request restrictions on certain uses and disclosures of PROTECTED HEALTH INFORMATION, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it. • The right to request to receive confidential communications of PROTECTED HEALTH INFORMATION from us by alternative means or at alternative locations. • The right to access, inspect and copy your PROTECTED HEALTH INFORMATION. • The right to request an amendment to your PROTECTED HEALTH INFORMATION. • The right to receive an accounting of disclosures of PROTECTED HEALTH INFORMATION outside of treatment, payment and health care operations. • The right to obtain a paper copy of this notice from us upon request. We are required by law to maintain the privacy of your PROTECTED HEALTH INFORMATION and to provide you with notice of our legal duties and privacy practices with respect to PROTECTED HEALTH We are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all PROTECTED HEALTH INFORMATION that we maintain. Revisions to our Notice of Privacy Practices will be posted on the effective date and you may request a written copy of the Revised Notice from this office. You have the right to file a formal, written complaint with us at the address below, or with the Department of Health & Human Services, Office of Civil Rights, in the event you feel your privacy rights have been violated. We will not retaliate against you for filing a complaint.
For more information about our Privacy Practices, please contact:

For more information about HIPAA or to file a complaint:
The U.S. Department of Health & Human Services PATIENT NAME _____________________________________________________ BIRTHDATE ___________________
Reason for Today’s Visit ___________________________________________ Date of last dental care __________________________________ Former Dentist __________________________________________________ Date of last dental X-Rays ________________________________ Address _______________________________________________________________________________________________________________ How did you find out about our office? _______________________________________________________________________________________ Are you satisfied with your smile? Yes No If not, do you want to improve it? Yes No Check (9) if you have had problems with the following: How often do you floss? ___________________________________________ How often do you brush? _________________________________ MEDICAL HISTORY
Physician’s Name ________________________________________________ Phone Number ________________________________________ Have you had any serious illnesses or operations? _______________ If yes, describe __________________________________________________ Yes No If yes, give approximate dates_____________________________________________ (Women) Are you pregnant? Yes No
Check (9) if you have or have had any of the following: OTHER ___________________________________________________________________________________________________________ MEDICATIONS
List medications you are currently taking: ______________________________________________________________ ______________________________________________________________ Pharmacy ____________________________ Phone ___________________ SIGNATURE
To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.
________________________________________________________________________ _______________________________________
Signature of Patient, Parent, Guardian or Personal Representative
________________________________________________________________________ _______________________________________
PLEASE PRINT NAME of Patient, Parent, Guardian or Personal Representative Relationship to Patient
________________________________________________________________________ _______________________________________
DATE _______________________
NAME ______________________________________________ MARRIED SINGLE MINOR MALE FEMALE LAST SOCIAL SECURITY # _____________________________ ADDRESS ________________________________________________________________________________________ STREET TELEPHONE (______)_____________________(______)_____________________(______)_____________________ HOME E-MAIL ADDRESS _________________________________________________________________________________ (To be used for appointment confirmations and/or office promotions…your e-mail address will NOT be sold) NAME OF EMPLOYER __________________________________ ADDRESS _________________________________ IF FULL TIME STUDENT, SCHOOL NAME ___________________________________________ GRADE ___________ PERSON RESPONSIBLE FOR ACCOUNT – PLEASE CHECK ONE: PATIENT GUARDIAN SPOUSE FATHER MOTHER MINOR CHILD – MAY NEED TO COMPLETE BOTH BLOCKS FOR PARENT INFORMATION INSURANCE INFORMATION

______________________________________________________________________________________________ LAST ______________________________________________________________________________________________ STREET CITY ______________________________________________________________________________________________ HOME ______________________________________________________________________________________________ BIRTHDATE (MO/DAY/YEAR) ______________________________________________________________________________________________ EMPLOYER ______________________________________________________________________________________________ SS# Has any member of your family ever been treated in our office ? Whom may we thank for referring you to our office ? ______________________________________________________________________________ PERSON TO CONTACT

NAME _____________________________________________________________________ TELEPHONE __________________________________
ADDRESS ________________________________________________________________________________________________________________
Responsible party currently has an account with this office I hereby authorize payment directly to the Dental office of the group insurance benefits otherwise payable to me. I understand that I am Payment in full at each appointment (cash or personal check) responsible for all costs of dental treatment. I hereby authorize the Dental Office to administer such medications and perform such diagnostic, Card # ________________________________ Exp. Date _________ photographic and therapeutic procedures as may be necessary for proper I wish to discuss the Dental Office’s Financial Policy dental care. The information on this page and the dental/medical histories SERVICE CHARGE
are correct to the best of my knowledge. I grant the right to the dentist to If I do not pay the entire new balance within _____ days of the monthly billing release my dental/medical histories and other information about my dental date, a service charge will be added to the account for the current monthly treatment to third party payors and/or other health professionals. billing period. The service charge will be a periodic rate of ____% per month (or a minimum charge of $_____ for a balance under $______) which is an X _________________________________________________________
annual percentage rate of _____% applied to the last month’s balance. In the case of default of payment, I promise to pay any legal interest on the balance due, together with any collection costs and reasonable attorney fees incurred to ___________________________________________________________ effect collection of this account or future outstanding accounts. PATIENT INFORMATION (Vers.1)
Patient Consent to receive Mail and/or Telephone Messages
Email Address (please print)
Do we have your permission to:

Send a recall appointment reminder to your home?
Leave appointment, billing or dental information on your answering machine/voice mail/e-mail: I give permission to share appointment, billing or dental information with the person named below: Name: _________________________________________________ ________________________________________________ ________________ Signature of Patient / Parent or Legal Guardian Acknowledgment of Receipt of Notice of Privacy Practices
I have received a copy of the Notice of Privacy Practices with an effective date of April 14, 2003. ________________________________________________ ________________ Signature of Patient / Parent or Legal Guardian HIPAA CONSENT
Financial Policy
Please note that as of June 1, 2005.
Some changes have been made to our Financial Policy.
All payments are due at the time services are started
unless arrangements are made prior to treatment.
Insurance balances are ultimately the patient’s obligation.
We file (most) insurances at no cost to you as a courtesy.
We are glad to offer this service. However, insurance balances
that are not paid after 60 days may be billed directly to you.
Please keep your walk out statements and follow up
with your insurance to ensure payment is in process.
Patient balances that go unpaid for 30 days or more may
incur the following additional charges:
Interest charges (1.5% per month or 18% APR),
collection fees (up to 42% of the full balance),
and/or legal charges.
Major services require a deposit of at least half the
estimated patient portion at the time the appointment is made.
Appointments not cancelled with 48 hour notice,
may result in charges for time reserved.
A fee of $30.00 will be assessed for NSF checks.

___________________________________ ___________________
Signature of patient/guardian

Witnessed By

Informed Consent Form for General Dental Procedures
You, the patient, have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment. Do not consent to treatment unless and until you discuss potential benefits, risks and complications with your dentist and all of your questions are answered. By consenting to treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the probability of occurrence. As with all surgery, there are commonly known risks and potential complications associated with dental treatment. No one can guarantee the success of the recommended treatment, or that you will not experience a complication or less than optimal result. Even though many of these complications are rare, they can and do occur occasionally. Some of the more commonly known risks and complications of treatment include, but are not limited to, the following: 1.) Pain, swelling, and discomfort after treatment; 8.) Allergic reaction to anesthetic or medication; 2.) Possible injury to the jaw joint and related 9.) A root tip, bone fragment or a piece of a dental structures requiring follow-up care and treatment, instrument may be left in your body, and may have to be removed at a later point in time; 3.) Temporary, or, on rare occasion, permanent 10.) If upper teeth are treated, there is a chance of a numbness, pain, tingling or altered sensation of sinus infection or opening between the mouth the lip, face, chin, gums and tongue along with and sinus cavity resulting in infection or the need 4.) Damage to adjacent teeth, restorations or gums; 11.) Infection in need of medication, follow-up 5.) An altered bite in need of adjustment; 12.) The need for replacement of restorations, implants or other appliances in the future; 6.) Possible deterioration of your condition which 13.) Need for follow-up care and treatment, including It is very important that you provide your dentist with accurate information before, during and after treatment. It is equally important that you follow your dentist’s advise and recommendations regarding medication, pre and post treatment instructions, referrals to other dentists or specialists, and return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome. Certain heart conditions may create a risk of serious or fatal complications. If you (or a minor patient) have a heart condition or heart murmur, advise your dentist immediately so he/she can consult with your physician if necessary. The patient is an important part of the treatment team. In addition to complying with the instructions given to you by this office, it is important to report any problems or complications you experience so they can be addressed by your dentist. If you are a woman on birth control medication, you must consider the fact that antibiotics might make oral birth control less effective. Please consult with your physician before relying on oral birth control medication if your dentist prescribes, or if you are taking antibiotics. This form is intended to provide you with an overview of potential risks and complications. Do not sign this form or agree to treatment until you have read, understood, and accepted each paragraph stated above. Please discuss the potential benefits, risks and complications or recommended treatment with your dentist. Be certain all of your concerns have been addressed to your satisfaction by your dentist before commencing treatment.
_________________________________________ _______________________________________________________

_________________________________________ _______________________________________________________
Signature of parent (if a Minor) or Legal Guardian GENERAL CONSENT
Information Regarding Bisphosphonates
Bisphosphonates are a class of drugs that are used to treat osteoporosis in women. Stronger forms of bisphosphonates are sometimes used in the treatment of certain cancers, as well as for a disorder called Paget’s disease. A connection has been made between bisphosphonate type drugs and a serious bone disease called Osteonecrosis of the Jaw. The United States Food and Drug Association, along with the manufacturer of one of these drugs (Fosamax) issued a warning to health care professionals on this issue on September 24th, 2004. It is very important for you to let us know if you are now, or have ever taken in the past, ANY type of bisphosphonate class drug. If we treat you without knowing if you are now taking, or have taken in the past, any of these drugs, your health could be seriously affected. These drugs continue to affect the body for years after they are no longer being taken, so we must know if you have ever taken any of them. Brand names of these drugs include (but may not be limited to) are: Didronel
Are you now, or have you in the past, taken a bisphosphonate drug, including any of the brands
YES __________ NO __________ DATE __________________________
Patient’s Signature
Information on the Election of Treatment Options

Your dentist will design a treatment plan in which he/she will recommend that you undergo specific dental procedures. You will be
presented with the optimum treatment for your particular dental needs. If, in the dentist’s judgment, other acceptable treatment options
exist, these will be discussed with you as well. There are likely to be increased risks and potential complications should you elect to
have an alternative form of treatment that differs from the optimum treatment plan presented to you. Please discuss these issues in
more detail with your dentist. Be sure to understand the potential risks and complications before consenting to treatment.
_________________________________________ _______________________________________________________

_________________________________________ _______________________________________________________
Signature of parent (if a Minor) or Legal Guardian

Source: http://pikesvilleendodontics.com/wp-content/uploads/2012/01/New-Patient-Forms.pdf


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