ADULT HEALTH HISTORY
In order to assist you in determining and receiving your orthodontic insurance benefit, please complete the following information:
The above named patient of "Ann Arbor Orthodontics" hereby represents and warrants that they have the full legal right, power and authority to grant this agreement and hereby irrevocably consent the non-exclusive, irrevocable right, license, privilege and authority to "still" and/or "video" photograph the patient's image for the purpose, but not limited to, of company educational and promotional purposes throughout the world on any medium or forum, whether now known or hereinafter created.
This includes any photography taken before, during and after the patient's treatment.
Methods of advertising includes, but is not limited to, internal office posting, newspaper/magazine/billboard advertisements, promotional/educational materials and internet website.
The "still" or "video" images of the patient shall not be distributed or exploited separately or independently of "Ann Arbor Orthodontics"
Effective April 14, 2003, the new federal law known as the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") requires that this office comply with certain rules regarding the maintenance of the privacy of your information that we have collected and will collect in the future.
To comply with one of HIPAA’s requirements, we are giving you a copy of our Notice of Privacy Practices. This notice of Privacy Practices contains the information that HIPAA requires us to disclose regarding our privacy practices. Existing Michigan Law requires (in addition to our attempt to obtain your written acknowledgment, discussed above) us to first obtain your written consent prior to disclosing any of your information except for our disclosures in connection with: a defense to a claim challenging our professional competence; a review entity’s functions; a claim for payment of fees; a third party payer’s examination of our records; a court order as part of a criminal investigation; an identification of a dead body; a licensure investigation; or a child abuse/neglect investigation. From time to time it may be necessary for us to make disclosures of your information in connection with your treatment. For example, we make a referral to or consult with another dentist or health care professional, provide a specimen to a laboratory for testing or otherwise make disclosures of your information in connection with providing or coordinating your treatment.
We will only discuss your treatment with parents / legal guardians / the person financially responsible for your treatment and/or referring Doctors and Dentists for the furtherment of your treatment.