Patient Information

First Name:
MI:
Last Name:
Likes To Be Called:
Address:
City:
State:
Zip:
Gender:
Birthdate:
Social Security Number:
Email:
Home Phone:
General Dentist:
Last Visit:
Whom may we thank for referring you to our office:

Parent/Guardian/Responsible Party Information

First Name:
MI:
Last Name:
Marital Status:
Address:
City:
State:
Zip:
Birthdate:
Email:
Social Security Number:
Home Phone:
Cell Phone:
Work Phone:
Employer:
Occupation:
No. yrs employed:
Relationship to patient:
Are you the legal guardian?

Second Responsible Party Information

First Name:
MI:
Last Name:
Marital Status:
Address:
City:
State:
Zip:
Birthdate:
Email:
Social Security Number:
Home Phone:
Cell Phone:
Work Phone:
Employer:
Occupation:
No. yrs employed:
Relationship to patient:
Are you the legal guardian?

Insurance Information

I give permission to GO Orthodontics to verify and file the insurance provided for payment.
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Policy Holder's Address:
Insurance Company:
Subscriber ID:
Group No:
Insurance Co Address:
InsCity:
InsState:
InsZip:
Insurance Co Phone:
Policy Holder's Date of Birth:
Do you have dual coverage?
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Policy Holder's Address:
Insurance Company:
Subscriber ID:
Group No:
Insurance Co Address:
InsCity:
InsState:
InsZip:
Insurance Co Phone:
Policy Holder's Date of Birth:

Medical History

Is the child currenty under the care of a physician?
If yes, explain:
Has puberty begun?
What are the main concerns that you would like orthodontics to accomplish?
Has the patient ever been evaluated for orthodontic treatment?
Has the patient ever experienced jaw join pain/discomfort (TMJ/TMD)?
Does the patient have any missing or extra permanent teeth?
Has the patient ever had injury to: (Check all that apply)
Does/Has the patient ever had any of the following habits? (Check all that apply)
Does the patient have speech problems?
Is your child allergic to any of the following:
Other allergies/sensitivities:
List all drugs the patient is currently taking:
List any serious medical conditions:

Medical History Acknowledgement - Release

I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes of my child's medical status.

I hereby authorize verification and the release of any information related to insurance claims. I consent to examination by the doctor and I authorize payment of any insurance benefits to this office.

I understand that where appropriate, credit bureau reports may be obtained.

Signature:
Date:

Authorization For Specific Protected Health Information

PATIENT AUTHORIZATION FOR SPECIFIC DISCLOSURE OF PROTECTED HEALTH INFORMATION
Patient Name:
Patient DOB:
I, the undersigned hereby authorize GO Orthodontics Partnership to disclose certain protected health information about me to the following individual(s):
Name:
Address:
Relationship to Patient:
Phone:
Name:
Address:
Relationship to Patient:
Phone:
GO Orthodontics Partnership is hereby authorized to disclose the following protected health information.
Specifically describe the information to be disclosed if Specific Information is chosen, such as date(s) of services, type of services, level of detail to be released, origin of information, etc:
I understand that this request does not apply to: (1) certain health information that is not held in GO Orthodontics Partnership's medical records; (2) psychotherapy notes; (3) information compiled in reasonable anticipation of or for litigation; and (4) other health information not subject to the right of access under HIPAA.
Protected health information may be released for the following reason:

This authorization will expire 90 days after the date of its execution or on the date of my treatment completion, unless expressly revoked by me at an earlier time.

  • I understand that GO Orthodontics Partnership may not condition my treatment on whether I sign this authorization.
  • I understand that if my protected health information is disclosed to someone who is not required to comply with the federal HIPAA regulations, then such information may be re-disclosed by the recipient and may no longer be protected by HIPAA.
  • I understand that I may revoke this authorization at any time by delivering a revocation in writing to GO Orthodontics Partnership at the following address:

GO Orthodontics Partnership
2408 South Lamar Blvd, Ste. 2
Oxford MS 38655

If I revoke this authorization, it will have no effect on actions already taken by GO Orthodontics Partnership in reliance on this authorization.

I authorize the disclosure described herein. I have read and understand this authorization. I am the patient listed on this authorization or am authorized to act on behalf of the patient as the patient's personal respresentative.

I agree to these communication options about my account and treatment.
Text:
Email:
Signature of Patient or Legal Guardian:
Name of Patient or Legal Guardian:
Date:

Acknowledgement of Receipt of HIPAA Privacy Practices

For More Information or To Report a Problem

You have the right to complain to us and to the Secretary of the U.S. Department of Health and Human Services (HHS) if you believe we have violated your privacy rights. We will not retaliate against you for filing a complaint.

For more information or to file a complain with us, contact our Privacy Officer by phone or mail as follows:
Kristen Farmer, Privacy Officer
GO Orthodontics
PO Box 1218
Oxford, MS 38655
662-234-4822

To file a complaint with the Secretary of HHS, send your complain to:
Office for Civil Rights
U.S. Department of Health and Human Services
61 Forsyth Street, SW - Suite 3B70
Atlanta, GA 30323
404-562-7886; 404-331-2867 (TDD)
404-562-7881 FAX

If you have any questions or want more information about this Notice of Privacy Practices, please contact our Privacy Officer. By signing this document I am acknowledging receipt of a copy of the Notice of Privacy Practices for GO Orthodontics Partnership.

Signature of Patient or Personal Representative:
Date:
Patient Name: