Notice of Privacy Practices Acknowledgement Precision Dentures 4110 S. Highland Drive, Suite200 Salt Lake City, UT 84124 I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: n Conduct,
plan, and direct my treatment and follow-up among the multiple health care providers who may be involved in that treatment directly and indirectly. n Obtain payment from third-party payers. n Conduct normal health care operations such as quality assessments and physician certifications. I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
Patient Name
Signature
Relationship to Patient
Date
4110 S. Highland Drive, Suite 200 n Salt Lake City, UT 84124 n (801) 274-1775 Patient Information Patient Name
Date
First Preferred Name
Last
Birth Date
Social Security No.
Address Street Marital Status Driver’s License No.
Apt. No. Issuing State
Home Phone
City
Exp. Date
Cell Phone
State Male Employer
Work Phone
Zip Female Ext.
May we contact you there? Yes In case of emergency, please notify_______________________________________________ Phone No.
No
Whom may we thank for referring you to our office?_____________________________________________________________________________________________
Spouse Information (OR Parent Information, if patient is under age 18) Spouse or Parent Name Address
Birth Date
First
Last
Street Occupation Work Phone
Apt. No. Employer
City
State Zip Social Security No.
Ext.
Financial Information Person responsible for payments
Relationship to patient
Address Street Occupation
Apt. No. Employer
City
State Zip Phone No.
Insurance Information Dental Insurance
Phone No.
Group No.
Street Name of Insured (Policy Holder)
City Birth Date
State ID No.
Secondary Dental Insurance (if applicable)
Phone No.
Group No.
City Birth Date
State ID No.
Mailing Address Zip
Mailing Address Street Name of Insured (Policy Holder)
Zip
Patient Name ________________________________ Health History Are you in good health?
Yes
No
Do you have any disease, condition, or problem that you think our office should be aware of? If yes, please explain: Have you been hospitalized or had major surgery recently? If yes, please explain: For women, are you pregnant?
Yes
Yes No
No
Yes No Expected delivery date:
Are you satisfied with the appearance of your smile?
Yes
No
Do you have, or have you ever had, any of the following? Check all that apply:
AIDS/HIV positive Anemia Artificial heart valve Artificial joint replacement Asthma/Hay fever Birth defects Blood clots Bruise easily Cancer Chest pain/Angina Congenital heart disease Depression/PMS Diabetes Difficulty healing after a cut Dizziness/Fainting Eating disorders
Emphysema Heart attack/Arrhythmia Heart murmur Heart surgery/Pacemaker Hemophilia Hepatitis A Hepatitis B Hepatitis C High blood pressure Hypoglycemia Jaundice Kidney disease Loss of hearing Marked weight change Mitral valve prolapsed Numbness/Tingling
Persistent fever Persistent headaches Persistent sore throat Psychiatric disorder Radiation/Chemotherapy Rheumatic fever Stroke Tire easily/Weakness Thyroid condition Tuberculosis Tumors/Growths Ulcers Venereal Disease Other _________________________________ NONE
Are you allergic or have you had a reaction to any of the following? Check all that apply: Local anesthetic (lidocaine) Codeine Other antibiotics
Penicillin Metals Latex
Sulfa drugs Other _________________________________ NONE
Are you currently taking any of the following medications? Check all that apply:
Allergy/Cold medicine Antibiotics Antidepressant Aspirin/Arthritis medicine Birth control pills Blood pressure medicine
Blood thinners Cortisone/Steroids Digitalis/Heart medicine Dylantin/Seizure medicine Insulin/Diabetes medicine Nitroglycerin
Pain pills Recreational drugs Salt-free diet Others NONE
Patient Name ________________________________ Health Questionnaire Acknowledgement and Consent to Proceed I authorize Dr. Jack Brauer and/or such associates or assistants as he may designate to perform those procedures as may be deemed necessary or advisable to maintain my dental health or the dental health of any minor or other individual for which I have responsibility, including arrangement and/or administration of any sedative (including nitrous oxide), analgesic, therapeutic, and/or other pharmaceutical agent(s), including those related to restorative, palliative, therapeutic, or surgical treatments. I understand that the administration of local anesthetic may cause an untoward reaction or side effects, which may include, but are not limited to, bruising, hematoma, cardiac stimulation, muscle soreness, and, temporary or rarely, permanent numbness. I understand that occasionally needles break and may require surgical retrieval. I understand that as part of the dental treatment, including preventative procedures such as cleanings and basic dentistry, including fillings of all types, teeth may remain sensitive or even possibly quite painful both during and after completion of treatment. After lengthy appointments, jaw muscles may also be sore or tender. Gums and surrounding tissues may also be sensitive or painful during and/or after treatment. Although rare, it is also possible for the tongue, check, or other oral tissues to be inadvertently abraded or lacerated (cut) during routine dental procedures. In some cases, sutures or additional treatment may be required. I understand that as part of dental treatment, items including but not limited to crowns, small dental instruments, drill components, etc. may be aspirated (inhaled into the respiratory system) or swallowed. This unusual situation may require a series of x-rays to be taken by a physician or hospital and may, in rare cases, require bronchoscopy or other procedures to ensure safe removal. I do voluntarily assume any and all possible risks, including the risk of substantial and serious harm, if any, which may be associated with general preventive and operative treatment procedures in hopes of obtaining the potential desired results, which may or may not be achieved, for my benefit or the benefit of my minor child or ward. I acknowledge that the nature and purpose of the foregoing procedures have been explained to me if necessary, and I have been given the opportunity to ask questions. Financial Arrangements We offer five payment options to better serve you 1. A full 5% discount for prepayment in full, 2. Three (3) equal monthly payments with no interest, 3. Financing of your dental treatment through Care Credit, a medical finance company utilized by our office, 4. Pay as you go in full at each appointment, and 5. (for crown and bridge work), half due at the preparation appointment, and the remaining half due at the delivery appointment. Patients with Dental Insurance At the completion of your treatment, we will compile a detailed statement of treatment – complete with dates and appropriate insurance coding – for you to submit to your insurance carrier. Dental insurance is a contract between you and your insurance carrier; thus, we choose to make financial agreements with you directly. Insurance reimbursement funds will then go directly to you.
Signatures I certify I have read this agreement in its entirety, and by signature I agree to the terms set forth above.
Responsible Party’s Signature
Name (please print)
Date