Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Birthdate:
Cell Phone:
Home Phone:
Work Phone:
Email:
If patient is a minor, give parents' or guardians' name(s):
Please indicate approved methods of appointment reminders:
Whom may we thank for referring you to our office?

IF UNDER 18
School:
Siblings:
Hobbies:
Has any family member had braces before? If so, who?

Financial Party Information

First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Mailing Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:
Employer:
Occupation:
Work Phone:
Employer Address and Phone Number:
Relationship to Patient:
Social Security Number:

Spouse's Name:
Occupation:
Relationship to Patient:

Dental Insurance Information

Policy Holder's Name:
Relationship to Patient:
Birthdate:
Mailing Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Email:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Policy Holder's Employer:
Medicaid?

Additional Dental Insurance Information
Policy Holder's Name:
Relationship to Patient:
Birthdate:
Mailing Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Work Phone:
Email:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Policy Holder's Employer:

Emergency Contact Information

Name:
Relationship to Patient:
Phone:

Dental/Medical History

Dentist's Name:
Phone:
Date of last cleaning:
Physician's Name:
Phone:
Date of Last visit:
Has the patient had an orthodontic consult or treatment?
If so, when? Were x-rays taken?
Do you have any specific concerns?
If patient is a minor:
Mother's Height:
Father's Height:
Is the patient currently under a physician's care? If so, for what reason?
Has the patient had any serious illness or operations? If so, please describe.
Do you have any loose teeth?
Are you in dental pain?
Have you ever had periodontal treatment (deep gum cleaning)?
Do your gums bleed when you brush or floss?
Does food frequently get caught between your teeth?
Tonsils and adenoids been removed?
Have you ever been involved in a serious accident?
Have you ever had a bad reaction to a medical or dental procedure?
Have you lost or chipped permanent teeth?
Do you have any problems relating to your jaw joint?
Has the patient ever sucked a thumb or finger?
Please list any medications currently being taken by the patient (include non-prescription):
Has there ever been an adverse reaction to Latex or nickel?
Please list any other allergies or sensitivities (metal, food, drugs, etc):
Does the patient need antibiotics before seeing the dentist?
Has the patient ever had severe trauma to the face or teeth?
Has the patient ever had an issue with severe cavities?
Have you had your first menstruation cycle?
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Congenital heart lesions?
Heart murmur?
Rheumatic/Scarlet fever?
Tuberculosis?
Persistent cough?
Abnormal bleeding?
High/low blood pressure?
Diabetes?
Sores or lumps in mouth?
Pacemaker?
Nervousness/Anxiety?
Cancer or tumor?
HIV or AIDS?
Hepatitis?
Kidney problems?
Liver problems?
Stomach ulcers?
Mental Disorders?
Arthritis?
Chronic dry mouth?
Thyroid Disorders?
Eating Disorders?
Stroke?
Epilepsy or Seizures?
Fainting Spells?
Asthma?
Mouth Breathing?
Speech Problems?
Canker Sores?
Jaw Locking?
Sore Facial Muscles?
Sensitive Teeth?
Back Problems?
Bone disorders or loss?
Transplant Patient?
Jaw/Facial Injuries?
Dental/Tooth Injuries?
Frequent headaches?
Clenching/grinding of teeth?
Ringing in the ears?
Sinus trouble?
Smoke/chew tobacco?
Pregnant now?
Sore jaw in morning?
Blood Disorder?
Artificial joints?
Please describe any medical or dental problems not listed above:

Social Media and Advertising Release

Authorization: I authorize the use and disclosure of my name, photographic/video images, and/or testimonial for marketing purposes by Hancock Orthodontics. I understand that information disclosed pursuant to this authorization may be subject to redisclosure and my no longer be protected by HIPAA privacy regulations.

Purpose: The photographic/video images, and/or testimonial will be used for: Social Media and/or Advertising.

Revocability: I understand that I may revoke this authorization at any time, but such revocation must be in writing and received by Hancock Orthodontics via registered mail. Revocation affects disclosure moving forwrad and is not retroactive. This authorization expires 99 years from date signed.

No Treatment Conditions: I understand that the practice cannot condition treatment on whether or not I sign this authorization.

HIPPA Notice of Privacy Practices

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. If you have any questions about this Notice please contact our Privacy Contact representative, Andrea Hancock, 703-777-9200, andrea@hancockortho.com.

Your Rights: You have the right to: Get a copy of your paper or electronic medical record, correct your paper or electronic medical record, request confidential communication, ask us to limit the information we share, get a list of those with whom we’ve shared your information, get a copy of this privacy notice, choose someone to act for you, file a complaint if you believe your privacy rights have been violated.

Your Choices: You have some choices in the way that we use and share information as we: Tell family and friends about your condition, Provide disaster relief, Include you in a hospital directory, Provide mental health care, Market our services and sell your information, Raise funds.

Our Uses and Disclosures: We may use and share your information as we: Treat you, Run our organization, Bill for your services, Help with public health and safety issues, Do research, Comply with the law, Respond to organ and tissue donation requests, Work with a medical examiner or funeral director, Address workers’ compensation, law enforcement, and other government requests, Respond to lawsuits and legal actions.



Your Rights: When it comes to your health information, you have certain rights. This section explains your rights and some of our responsiblities to help you.

Get an electronic or paper copy of your medical record. You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record. You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications. You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.

Ask us to limit what we use or share. You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information. You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice. You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated You can complain if you feel we have violated your rights by contacting us using the information on page 1. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

Your Choices: For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to: Share information with your family, close friends, or others involved in your care, Share information in a disaster relief situation, Include your information in a hospital directory, If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission, Marketing purposes, Sale of your information, Most sharing of psychotherapy notes.

In the case of fundraising, We may contact you for fundraising efforts, but you can tell us not to contact you again.



Our Uses and Disclosures

How do we typically use or share your health information?
We typically use or share your health information in the following ways.

Treat you. We can use your health information and share it with other professionals who are treating you, Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization. We can use and share your health information to run our practice, improve your care, and contact you when necessary, Example: We use health information about you to manage your treatment and services.

Bill for your services. We can use and share your health information to bill and get payment from health plans or other entities, Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues. We can share health information about you for certain situations such as: Preventing disease, Helping with product recalls, Reporting adverse reactions to medications, Reporting suspected abuse, neglect, or domestic violence, Preventing or reducing a serious threat to anyone’s health or safety.

Do research. We can use or share your information for health research.

Comply with the law. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests. We can share health information about you with organ procurement organizations. Work with a medical examiner or funeral director: We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests. We can use or share health information about you, For workers’ compensation claims, For law enforcement purposes or with a law enforcement official, With health oversight agencies for activities authorized by law, For special government functions such as military, national security, and presidential protective services.

Respond to lawsuits and legal actions. We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

Changes to the Terms of this Notice: We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

This notice is effective July 1, 2009

Notice of Privacy Practices and Acknowledgement of Receipt
Consent to the use and disclosure of Health Information for treatment and payment purposes
Our office takes great care to protect your privacy relating to your health records describing your health history, examination results and diagnoses, treatments, and any plans for future care or treatment.
This information serves as a basis for planning your orthodontic care and treatment, a means of communication among the various health professionals who contribute to your care, and a source of information for billing purposes necessary for this office and/or a third-party payer. Any information you share with this office will be used for these purposes only.

Signature
Relationship to Patient: