Confidential Patient Information
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Patient First Name:
MI:
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Patient Last Name:
Nickname:
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Patient Birthdate:
Birthdate is not in correct format (mm/dd/yyyy, mm/dd/yy)
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Patient Gender:
Male
Female
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Address:
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City:
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State:
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Zip:
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Main Phone:
2nd/Cell Phone:
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Email:
Social Security #:
If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does the patient live with?
Select
Father
Mother
Parents
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
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First Name:
Middle Initial:
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Last Name:
Marital Status:
Select
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
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Birthdate:
Birthdate is not in correct format (mm/dd/yyyy, mm/dd/yy)
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Address:
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City:
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State:
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Zip:
Email:
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Main Phone:
2nd/Cell Phone:
Social Security #:
Work Phone #:
Employer:
Occupation:
Length of Employment:
Spouse or Other Parent's
First Name:
Middle Initial:
Last Name:
Social Security #:
Birthdate:
Birthdate is not in correct format (mm/dd/yyyy, mm/dd/yy)
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Employer:
Occupation:
Length of Employment:
Work Phone #:
Dental Insurance Information
Do you have insurance that covers orthodontics?
Policy Holder's Name:
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Relationship to Patient:
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Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
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Insurance Company:
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Subscriber ID #:
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Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Do you have dual dental coverage?
(If yes, complete information below)
No
Yes
Policy Holder's Name:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Dental History
Dentist Name:
Check-up Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
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Does the Patient need to premedicate prior to dental visit?
No
Yes
What is the patient's main orthodontic concern?
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
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Speech problems/therapy?
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No
Yes
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Clench or Grind Teeth?
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No
Yes
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Oral habits (thumb/finger sucking, lip/nail biting)?
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No
Yes
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Injury to face, jaw, teeth or mouth?
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No
Yes
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Pain, tenderness or noise in either jaw?
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No
Yes
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Chipped or injured permanent teeth?
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No
Yes
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Previous periodontal (gum) treatment?
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No
Yes
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Abnormal swallowing (tongue thrust)?
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No
Yes
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Mouth breathing?
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No
Yes
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Snores during sleep?
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No
Yes
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Bleeding gums?
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No
Yes
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Other periodontal (gum) problems?
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No
Yes
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Is there any dental work yet to be completed?
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No
Yes
If any of the above dental questions were answered 'Yes', please explain:
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Have you had a TMJ screening?
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No
Yes
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Do you experience soreness in the muscles of your face or around your ears?
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No
Yes
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Do you have a history of jaw joint problems?
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No
Yes
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Have you been treated for "TMJ"?
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No
Yes
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Do you notice clicking or popping in your jaw joint?
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No
Yes
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Do you clench your teeth?
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No
Yes
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Has your jaw ever locked?
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No
Yes
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Do you have difficulty chewing or opening your mouth?
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No
Yes
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Does your bite feel uncomfortable or unusual?
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No
Yes
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Frequent headaches/Migraines?
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No
Yes
If any of the above TMJ questions were answered 'Yes', please explain:
Medical History
Physician Name:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
Address:
City:
State:
Zip:
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Has there been any change in the patient's general health within the last year?
No
Yes
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Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
No
Yes
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Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?
No
Yes
List any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
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Latex
No
Yes
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Penicillin or other antibiotics
No
Yes
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Sulfa drugs
No
Yes
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Aspirin, Ibuprofen, Tylenol
No
Yes
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Local anesthetics
No
Yes
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Codeine or other narcotics
No
Yes
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Other:
No
Yes
List any drug allergies or sensitivities (not listed above) that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
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Heart Murmur
No
Yes
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Damaged or artificial heart valves
No
Yes
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Congenital Heart Defect
No
Yes
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Heart Disease
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No
Yes
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Rheumatic Fever
No
Yes
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Angina
No
Yes
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Liver Disease / Jaundice / Hepatitis
No
Yes
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Kidney Disease
No
Yes
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Heart Attack/Stroke
No
Yes
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Hemophilia
No
Yes
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Hypertension/High Blood Pressure
No
Yes
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Prolonged Bleeding/Transfusion
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No
Yes
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Anemia / Blood disorder
No
Yes
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HIV/AIDS
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No
Yes
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Tonsils/Adenoids Removed
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No
Yes
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Handicaps/Disabilities
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No
Yes
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Arthritis / Joint problems
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No
Yes
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Large Tonsils
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No
Yes
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Sinus trouble
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No
Yes
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Bed wetting
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No
Yes
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Substance abuse problem (past or present)
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No
Yes
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Bone fractures/trauma to face/jaw
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No
Yes
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Prosthetic joints
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No
Yes
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Chronic fatigue
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No
Yes
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Diabetes
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No
Yes
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Growth Problems
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No
Yes
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Tuberculosis or Lung Disease
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No
Yes
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Pneumonia
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No
Yes
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Cancer
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No
Yes
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Family History of Cancer
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No
Yes
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Received Radiation Treatment
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No
Yes
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Arteriosclerosis
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No
Yes
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Thyroid / Endocrine Problems
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No
Yes
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Stomach ulcer or hyperacidity
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No
Yes
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Hormone Therapy
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No
Yes
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Metal Allergy
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No
Yes
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Nervous Disorders
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No
Yes
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Bone Disorders/Bone Loss
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No
Yes
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Seizures / Epilepsy / Neurological Disease
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No
Yes
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Treated for Emotional Problems
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No
Yes
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Asthma
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No
Yes
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Respiratory problems / Emphysema
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No
Yes
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Persistent swollen neck glands
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No
Yes
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Sexually transmitted disease
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No
Yes
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Low blood pressure
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No
Yes
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Persistent cough
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No
Yes
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FEMALES: Are you pregnant
No
Yes
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Take Bisphosphonates (Fosamax, Boniva)
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No
Yes
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If any of the above medical questions were answered 'Yes' , please explain:
Patients Under 18
If patient is under the age of 18, please answer the following questions:
Height:
Weight:
School:
Grade:
Has patient begun puberty:
No
Yes
If patient is a girl, has menstruation begun:
No
Yes
If patient is a boy, has their voice changed or have facial hair:
No
Yes
Has the patient grown in the past year or has their shoe size changed recently:
No
Yes
Has either biological parent ever had orthodontic treatment:
Don't know
No
Yes
I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.
HIPAA Notice of Privacy Practices Brace Busters Orthodontics Roxborough | Dresher | South Phildelphia 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. This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected heath information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. Uses and Disclosures of Protected Health Information Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment. We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers’ Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500. Other Permitted and Required Uses and Disclosures Will Be Made Only With Your Consent, Authorization or Opportunity to Object unless required by law. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization. Your Rights Following is a statement of your rights with respect to your protected health information. You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in the Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically. You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. This notice was published and became effective on/or before April 14, 2003. We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number. Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:
Signature:
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