Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Age:
Gender:
Male
Female
Other
Cell Phone:
Main Phone:
Email:
Address:
City:
State:
Zip:
How did you hear about our office?
Responsible Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Social Security Number:
Cell Phone:
Email:
Employer:
Address:
City:
State:
Zip:
Marital Status:
Single
Married
Divorced
Seperated
Spouse's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Social Security Number:
Cell Phone:
Email:
Employer:
Address:
City:
State:
Zip:
Insurance Information
Policy Holder's Name:
Date of Birth:
Social Security #:
Policy Holder's Employer:
Insurance Company Name:
Group Number:
Policy Number:
Member ID:
Do you participate in a Flex Spending Account?
Yes
No
Secondary Coverage? If yes, please continue.
Yes
No
Policy Holder's Name:
Date of Birth:
Social Security #:
Policy Holder's Employer:
Insurance Company Name:
Group Number:
Policy Number:
Member ID:
Medical History Information
Physician Name:
Address:
City:
State:
Zip:
Does the patient have a history with any of the following (check those that apply):
Diabetes
Cancer / Radiation / Chemotherapy
AIDS / HIV Positive
Hepatitis
History of eating disorder (anorexia/bulemia)
Excessive Bleeding
Learning disabilities
Seizures / Epilepsy / Fainting Spells
Latex or Nickel allergy/sensitivity
Does the patient have any allergies to other medications, foods, or over-the-counter substances? If yes, please explain:
Is the patient taking any medications currently? If yes, please list:
Has the patient taken, now or in the past, bisphosphonates (such as Fosamax, Boniva, Didronel, Aredia, Actonel, Skelid, Zometa)? If yes, which drug:
Are there any other medical conditions, currently or in the past, that have not been mentioned but that we should be aware of? If yes, please explain:
For female patients:
To help us asses your daughter's growth, has she started menstruating?
Yes
No
If so, at what age?
Is the patient pregnant?
Yes
No
Dental Health Information
Have you ever had a previous orthodontic consultation or orthodontic treatment? If yes, please explain:
Please list any family members who have received orthodontic care in our office:
Who is your general/pediatric dentist:
Is the patient seen for routine check-ups every 6 months?
Yes
No
Does the patient have any of the following (check those that apply):
History of gum disease?
Pain in the jaw joint?
Thumb / Finger sucking habit?
Cavities that currently require dental work?
HIPAA Notice of Privacy Practices Appel Orthodontics 211 Geiger Road, Suite A, Philadelphia, PA 19115 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:
I have read and understand all of the above questions.
I will not hold Appel Orthodontics or any member of its staff responsible for any errors or omissions that I have made in completing this form. If there are any changes to the information I have presented on this date, I will inform Appel Orthodontics.
Patient / Parent / Guardian Signature:
By typing my name above I am electronically signing this form.