PATIENT INFORMATION
Birth Date:
Prev. Visit:
PRIMARY DENTAL INSURANCE
Insured's Birth Date:
By checking this box,
I authorize my insurance company to pay the dentist all insurance benefits rendered.
I authorize the use of this electronic signature on all insurance submissions.
I authroize the dentist to release all information necessary to secure the payment benefits.
I understand that I am financially responsible for all charges whether or not paid by insurance.
SECONDARY DENTAL INSURANCE
Insured's Birth Date:
By checking this box,
I authorize my insurance company to pay the dentist all insurance benefits rendered.
I authorize the use of this electronic signature on all insurance submissions.
I authroize the dentist to release all information necessary to secure the payment benefits.
I understand that I am financially responsible for all charges whether or not paid by insurance.
MEDICAL HISTORY
Are you under the care of a physician? YesNo
Please check your response to indicate if you have or have had any of the following:
Allergy Anesthetics
Allergy Aspirin
Allergy Codeine
Allergy Latex
Allergy Metals
Allergy Other
Allergy Penicillin
Allergy Seasonal
Allergy Sulfa Drug
Anemia
Arthritis
Artificial Joints
Asthma
Autoimmune Disease
Blood Disease
High Blood Pressure
Low Blood Pressure
Cancer
Diabetes
Emphysema
Epilepsy
Excessive Bleeding
Fainting/Dizziness
Glaucoma
Growths
Head Injuries
Heart Angina
Heart Attack
Heart Damaged Valves
Other Heart Disease
Heart Disease
Heart Endocarditis
Heart Failure
Heart Murmur
Heart Pacemaker
Heart Rheumatic
Heart Transplant
Heart Valve Prolapse
Cardiovascular
Prosthetic Valve
Hepatitis
High Colesterol
HIV/AIDS
Jaundice
Kidney Disease
Liver Disease
Liver Transplant
Mental Disorder
Nervous Disorder
Neroulogical Disorder
Pre-Medicates
Radiation Treatment
Respiratory Problems
Rheumatic Fever
Rheumatism
Sinus Problem
STD
Stomach Problems
Stroke
Tuberculosis
Tumors
Ulcers
Arteriosclerosis
Systemic Lupus Erythematosus
Bronchitis
Chest Pain Upon Exertion
Chronic Pain
Eating Disorder
Malnutrition
Gastrointestinal Disease
G.E. Reflux/Persistant Heartburn
Thyroid Problems
Sleep Disorder
Mental Health Disorder
Recurrent Infections
Night Sweats
Osteoporosis
Persistant Swollen Glands in Neck
Severe Headaches/Migraines
Severe or Rapid Weight Loss
Excessive Urination
Have you had a serious illness, operation or been hospitalized in the past 5 years? YesNo
Are you taking or have you recently taken any perscription or over the counter medicine(s)? YesNo
Have you had an orthopedic total joint replacement? YesNo
If yes, please provide date:
Do you use controlled substances (drugs)? YesNo
Do you use tobacco (smoking, snuff, chew, bidis)? YesNo
By checking this box, I acknowledge that above information is correct and I understand it is my responsibility to inform the office of any changes in my health as soon as possible.
FINANCIAL POLICY

Our team is delighted to welcome you to our practice and we are all pleased that you have chosen us to serve your dental needs. We are committed to the success of your treatment. Please understand that payment of your bill is considered part of your treatment. The following statement is our financial policy, which we request you to read and sign prior to services in our office.

We will file your dental claim form as a courtesy to you. We will do all that we can to maximize your benefits. Please be aware that some of the services provided may be noncovered services or considered above the usual and customary. Insurance is never a guarantee of payment. It is the patient?s responsibility to know his or her insurance benefits.

In an effort to keep timely appointments, our office does not double book appointment times. Our time is reserved and dedicated solely to you. If you must change an appointment, please give us at least 24 hours notice, otherwise we reserve the right to charge you the $50 broken appointment fee. Please help us to serve you better by keeping scheduled appointments.

I consent to dental diagnosis and/or treatment by Dr. Andrew Calhoun. I understand that Dr. Andrew Calhoun will explain my options for attaining and maintaining optimal dental health. I understand that I am responsible for all fees incurred regardless of insurance coverage. I authorize assignment of benefits from and release of information to my insurance company applicable to treatment and insurance claims. I understand that payment is due at the time services are rendered. Any outstanding balance will be paid within 60 days. In the event that payment is not received with in that time, I agree to pay all costs of collections and/or late fees. My insurance coverage is an agreement between my insurance company and me. I also understand that all information will be held in the strictest confidence.

By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the Office Financial Policy.
NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEAL TH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEAL TH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person?s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information. Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization. Required by Law: We may use or disclose your health information when we are required to do so by law. Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information.

USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example: Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you. Payment: We may use and disclose your health information to obtain payment for services we provide to you. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person?s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information. Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization. Required by Law: We may use or disclose your health information when we are required to do so by law. Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances. Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters). PATIENT RIGHTS Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We reserve the right to charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $0.25 for each page, $15 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost­based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request. Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances. Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail}, you are entitled to receive this Notice in written form.

QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the HIPAA Disclosure Form.
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