Patient registration

DAVID J. ADAMS, DMD, MS, PA
PATIENT REGISTRATION
Patient Information
Patient’s Name ______________________________________________ Preferred Name ___________ Address ______________________________________________________________________________ Street City State Zip Home Phone _________________ Work Phone ________________ Cell Phone ________________ Gender: † Male † Female Marital Status: † Married † Single † Divorced † Separated † Widowed Birthdate _________________ SS # _____________________ DL # ____________________ Email address ___________________________________ † I would like to receive correspondences via email Responsible party (If someone other than the patient) __________________________________________________________ General Dentist ______________________________________________ Medical Doctor(s) _____________________________________________ Pharmacy Name ______________________________________________ Dental Insurance Information
Are you covered by dental insurance? † No † Yes – please provide the insurance card for our records Name of Insured ___________________________________ Relationship to Patient: † Self † Spouse † Child † Other Insured SS # ______________________ Insured’s Employer _________________________________ Employer Address ______________________________________________________________________ Dental Insurance Company ___________________________ Do you have secondary insurance? † No † Yes – please provide the insurance card for our records MEDICAL HISTORY
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Please answer the following questions as thoughtfully and thoroughly as possible. If † Yes † No Are you under a physician’s care now? † Yes † No Have you ever been hospitalized or had a major operation?_____________________________ † Yes † No Have you ever had a serious head or neck injury? † Yes † No Are you taking any medications, pills, or drugs? † Yes † No Do you take Coumadin or Plavix? † Yes † No Do you take vitamins/supplements/herbals? _____________________________ † Yes † No Have you ever taken Fosamax / Boniva / Actonel / Didronel? ________________ † Yes † No Do you take, or have you taken, Phen-Fen or Redux? † Yes † No Do you use controlled substances? † Yes † No Do you have osteoporosis or osteopenia?
Women:
† Yes † No Are you pregnant / trying to get pregnant?
† Yes † No Are you nursing?
† Yes † No Are you taking oral contraceptives? Are you allergic to any of the following? † Sulfa drugs † Other: ____________________________________________________________________ Please describe reaction to each allergy: _______________________________________________________ If no allergies, then check here: † No Known Allergies Do you have or have you ever had, any of the following? † AIDS/HIV positive † Frequent headaches † Irregular heartbeat † Cold sores/fever blisters † Genital herpes † Congenital heart disorder † Glaucoma † Heart trouble/disease † Pain in jaw joints † Fainting spells/dizziness † High blood pressure † Renal dialysis Have you ever had any serious illness or symptom not listed above? † Yes † No If yes, please explain: To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the dental office of any changes in medical status. SIGNATURE OF PATIENT, PARENT OR GUARDIAN ______________________________________________ DATE ____________
Financial Policy

It is the policy of this office that all fees are payable at the time of service.
We accept cash, personal single party checks, Mastercard, Visa, American
Express & Discover.
As a courtesy to you, if you have dental insurance, we will provide a printed
claim form so that you may file the claim with your insurance company.
You will be expected to pay in full at the time of service and your insurance
company will send any reimbursement directly to you. It is your
responsibility to check on claims; however, we will assist you with any
information requested by your insurance carrier. Remember, your insurance
policy is an agreement between you and your insurance company. We are
only a third party to this agreement. No insurance company attempts to
cover all dental costs.
If you have any questions regarding your insurance or our financial policy,
please discuss them with the business staff prior to your services.
Any parent who brings a minor child for services will be responsible for
payment regardless of which parent provides dental insurance for the child.
Any unpaid balance will be charged a financial fee of 18% APR. Any fees
incurred such as attorney or collection fees on overdue accounts will be
charged to the patient.
To avoid a missed appointment charge of $50, a 24 hour cancellation notice
is required.
I have read the above and understand all fees are my financial responsibility.
_________________________________________
Effective date of notice: December 1, 2005 NOTICE OF PRIVACY PRACTICES
Dr. David J. Adams, DMD, MS, PA
925 Heather Park Drive / Garner, NC 27529 / Phone 919-772-0314 / Fax 919-772-2606 _______________________________________________________________________________
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.

We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you
notice of our privacy practices. This Notice describes how we protect your health information and what rights you have
regarding it.
TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS -- The most common reason why we use or disclose
your health information is for treatment, payment or health care operations. Examples of how we use or disclose
information for treatment purposes are: setting up an appointment for you; examining your teeth; prescribing medications
and faxing them to be filled; referring you to another doctor or clinic for other health care or services; or getting copies of
your health information from another professional that you may have seen before us. Examples of how we use or
disclose your health information for payment purposes are: asking you about your health or dental care plans, or other
sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a
collection agency or attorney). "Health care operations" mean those administrative and managerial functions that we
have to do in order to run our office. Examples of how we use or disclose your health information for health care
operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care
plans; defense of legal matters; business planning; and outside storage of our records. We routinely use your health
information inside our office for these purposes without any special permission. If we need to disclose your health
information outside of our office for these reasons, we usually will not ask you for special written permission.

USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION -- In some limited situations, the law
allows or requires us to use or disclose your health information without your permission. Not all of these situations will
apply to us; some may never come up at our office at all. Such uses or disclosures are:
• when a state or federal law mandates that certain health information be reported for a specific purpose;
• for public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices; • disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence; • uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws; • disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or • disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else; • disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations; • uses or disclosures for health related research; • uses and disclosures to prevent a serious threat to health or safety; • uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service; • disclosures of de-identified information; • disclosures relating to worker's compensation programs; • disclosures of a "limited data set" for research, public health, or health care operations; • incidental disclosures that are an unavoidable by-product of permitted uses or disclosures; • disclosures to "business associates" who perform health care operations for us and who commit to respect the privacy Unless you object, we will also share relevant information about your care with your family or friends who are helping you with your dental care. APPOINTMENT REMINDERS -- We may call or write to remind you of scheduled appointments, or that it is time to
make a routine appointment. We may also call or write to notify you of other treatments or services available at our office
that might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a post card, and/or leave
you a reminder message on your home answering machine or with someone who answers your phone if you are not
home.

OTHER USES AND DISCLOSURES -- We will not make any other uses or disclosures of your health information unless
you sign a written "authorization form." The content of an "authorization form" is determined by federal law. Sometimes,
we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if
it's your idea for us to send your information to someone else. Typically, in this situation you will give us a properly
completed authorization form, or you can use one of ours. If we initiate the process and ask you to sign an authorization
form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign
one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing.
Send them to the office contact person named at the beginning of this Notice.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION -- The law gives you many rights regarding your health
information. You can:
• ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or
health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to the office contact person at the address, fax or E Mail shown at the beginning of this Notice. • ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using E mail to your personal E Mail address. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice. • ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us (or sixty days if the information is stored off-site). You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice. • ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30 day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to the office contact person at the address, fax or E mail shown at the beginning of this Notice. • get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want). By law, the list will not include: disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30 day extension of time if we notify you of the extension in writing. If you want a list, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice. • get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you got one electronically or in paper form already. If you want additional paper copies, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice. OUR NOTICE OF PRIVACY PRACTICES -- By law, we must abide by the terms of this Notice of Privacy Practices until
we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change this
Notice, the new privacy practices will apply to your health information that we already have as well as to such information
that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office,
have copies available in our office, and post it on our Web site.
COMPLAINTS -- If you think that we have not properly respected the privacy of your health information, you are free to
complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against
you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the
address, fax or E mail shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by
phone.
FOR MORE INFORMATION -- If you want more information about our privacy practices, call or visit the office contact
person at the address or phone number shown at the beginning of this Notice.
Dr. David J. Adams, DMD, MS, PA
Periodontics & Implant Dentistry
Phone 919-772-0314 / Fax 919-772-2606 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
CONSENT TO TREATMENT
• We invite you to discuss with us any questions regarding our services. The best Dental health services are based on a friendly, mutual understanding between provider and patient. • I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims and to communicate with the referring dentist. • I acknowledge that I received a copy of Dr. Adams' Notice of Privacy Practices. Patient name (printed) ______________________________________________________________ Signature ______________________________________________ Date _____________________

Source: http://www.adamsperio.com/assets/pdf/patient_registration_form.pdf