Patient Information Form

HIPAA Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IF 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 purposed that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health 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.

1. Uses and Disclosures of Protected Health Information

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 care 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 appointments.

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 Disease: 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 Nation 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 Departments 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 the statement of your rights with respect to your protected health information.

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You have the right to inspect and copy your protected health information: Under federal law, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, 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 this 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 n 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 an 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 any changes. You then have the right to object or withdraw as provided in this notice.

Complaints: You may complain to us or 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.

We are required by law to maintain the privacy of, and provided individuals with, this notice of our legal duties to 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.

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NEW PATIENT INFORMATION
The information provided is strictly confidential. Please print legibly

Today's date:

Patient's legal name:

Nickname:

Birthdate:

Sex M/F:

M F

Address:

City, State, Zip:

Cell phone:

Email address:

Cell phone carrier (i.e. AT&T Verizon, etc.):

Family members or friends currently or previously seen by us:

Previous orthodontic consultation?

Yes

If so, when/where?

Previous orthodontic treatment?

Yes

If so, when/where?

Who may we thank for referring you to our office?

School Attending/Grade:

RESPONSIBLE PARTY INFORMATION

Name

Rel. to patient:

Marital Status: S

Address:

Cell/Work #:

City, State, Zip:

Birthdate:

Email address:

Occupation:

Years:

Employed by:

Rel. to patient:

Spouse's name:

Cell/Work #:

Email address:

Birthdate:

Employed by:

Occupation:

Years:

DENTAL INFORMATION

Dentist's Name

Does the patient receive regular checkups? Yes

Last dental exam:

Other dental specialists:

Have you been satisfied with the past dentistry?

Yes

If No, please explain

Does the patient currently have, or have had any of the following? (please check)

Clenching/Grinding

Gum Surgery/Food Traps

Thumb/Finger Habit

Nail Biting

Periodontal Disease

Head/Neck Injury

Jaw/Joint Pain/Head/Neck Pain

Colds Sores

Is there any other dental information we should know about:

MEDICAL INFORMATION

Physician's name:

Patient's overall health: Excellent Good Poor

Is the patient allergic to anything (drugs/food/pollen):

Is the patient currently under medical care?

Yes

Where/When?

Is the patient currently taking any medications?

Yes

Please list:

Does the patient currently have, or had any of the following? (please check)

Adenoid Removed

AIDS (HIV)

Arthritis

Asthma

Auto Accident

Bleeding Disorders

Cancer

Cosmetic Surgery

Diabetes

Drug History

Epilepsy/Seizures

Heart Problems

Hepatitis A, B or C

High Blood Pressure

Immune Disorders

Kidney Problems

Liver Problems

Lung Problems

Major Surgery

Nasal/Airway Problems

Sinus Problems

Speech Problems

Tobacco Usage

Tonsils Removed

Tuberculosis

Tubes in Ears

Venereal Disease

Is there any other medical information we should know about?

EMERGENCY INFORMATION

Name:

Relationship to patient:

Cell/Work phone #:

*Signature: (Please sign and date today)

Today's Date:

ORTHODONTIC INSURANCE INFORMATION
(The information provided is strictly confidential. Please print legibly)

We will be happy to assist you in determining your orthodontic insurance benefits, however all information must be completed and signed by the insured party.

Patient's legal name:

Preferred name:

Birthdate:

Age:

Sex:M

PRIMARY DENTAL INSURANCE

Name of insured:

Birthdate:

Home Address:

City, State, Zip:

Home phone:

Cell phone:

SS# of Insured:

Relationship to patient:

Employer:

Occupation:

Address:

City, State, Zip:

Telephone #:

Insurance company:

Group #:

ID #:

Address:

City, State, Zip:

Telephone #:

I understand that upon my request you will file any charges incurred at your office with my insurance company, however there is no guarantees of coverage and I am ultimately responsible for the account.

I hereby authorize release of any information relating to this claim and authorize payment directly to Abdoney Orthodontics.

Today's Date:

Signature below is only acknowledgment that you have received or reviewed this Notice of our Privacy Practice.

Patient Name:

Date:

Signature (Sign with mouse)

Responsible Party Name:

Date:

Signature (Sign with mouse)

Informed Consent for Treatment

Successful orthodontic treatment is a partnership between the doctor, the team, and the patient.

The Practice is dedicated to achieving the best possible outcome, and an informed and cooperative patient can help bring about positive treatment results. The patient and/or the patient's responsible party/authorized representative should be aware that, along with the benefits of a healthy smile, orthodontic treatment also presents limitations and potential risks.

Although these risks are typically not serious enough to forgo treatment, the patient and/or the patient's responsible party/authorized representative should always consider alternatives, which can include prosthetic solutions or limited treatment options, and should discuss all options with the Practice prior to beginning the treatment process.

RISKS AND LIMITATIONS OF ORTHODONTIC TREATMENT

Tooth Decay, Stains, Decalcification, and Unexpected Tooth Eruption: Poor oral hygiene causes gum inflammation, decalcification (white scars on the teeth), and decay. Additionally, inflamed gum tissue slows tooth movement and prolongs treatment. Patients should brush after every meal (at least three times a day), floss once a day, minimize sugar intake (especially soda) while in treatment, and maintain regular appointments and cleanings with their primary dentist. Additionally, erupting teeth can become impacted or ankylosed (fused to the bone and un-removable), and may require treatment changes or possible tooth extraction. The Practice will monitor the patient's bone growth, including tooth formation and eruption.

Routine Dental Visits: The American Dental Association and the Practice recommend that patients continue to see their regular dentist for checkups and cleanings at a minimum every six months or as otherwise recommended by the patient's primary dentist.

Speech: Certain treatments or products, such as Invisalign® products, can temporarily affect speech or result in a lisp. However, such speech impediments should be temporary.

Care of Appliances: A lost, broken, or bent appliance will disrupt treatment and may result in unwanted tooth movement. The patient and/or the patient's responsible party/authorized representative should notify the Practice immediately if an appliance becomes lost or damaged.

Auxiliary Appliances: The patient may be asked to wear elastics (rubber bands) or other auxiliaries during treatment to enhance tooth movement. Treatment will not proceed as planned if such auxiliary appliances are not worn as instructed.

Correct Use of Appliances: Appliances are designed to deliver forces in a specific manner, and if they are not worn as instructed, treatment will not proceed as planned.

Injury from Orthodontic Appliances: Although orthodontic appliances are designed for maximum strength, injuries may still occur, and orthodontic appliances and/or their parts could be accidentally swallowed or aspirated. The patient and/or the patient's responsible party/authorized representative should immediately report any injury to the Practice.

Wisdom Teeth: Tooth alignment can change as third molars (wisdom teeth) erupt. Consistently wearing retainers can help minimize these effects; however, the Practice will monitor the patient's tooth alignment to determine if, or when, tooth extraction becomes necessary.

Occlusal/Enamel Adjustment: Enomeloplasty or "manicuring" the teeth by altering their shape or otherwise removing enamel may be necessary to prevent relapse or to produce the best functional and esthetic results.

Unexpected Growth Changes: Facial structure and tooth eruption can be unpredictable and may affect the jaw relationship if they occur disproportionately. Changes following treatment may require further attention or possible surgery.

Inflammation or Recession of the Soft Tissues: Orthodontic appliances can irritate soft tissue in the mouth; however, this usually heals fairly quickly. Lack of proper oral hygiene may cause gum tissue inflammation or other severe reactions that could require referral to a periodontal specialist.

Informed Consent for Treatment

Results of Treatment: Orthodontic treatment usually proceeds as planned, and the Practice intends to do everything possible to achieve the best results for every patient. However, the Practice cannot guarantee complete satisfaction with results, nor can all complications or consequences be anticipated or overcome. The success of treatment depends on the patient and/or the patient's responsible party/authorized representative's cooperation and compliance with keeping appointments, maintaining good oral hygiene, avoiding loose/lost/broken appliances, and following the Practice's instructions.

Stability of the Result: Teeth and jaw structures constantly change, and tooth positions may not perfectly stabilize even after treatment. Wearing a retainer can help minimize these effects; however, teeth will slowly change position, and some problems may reoccur if a retainer is not worn as the Practice instructs.

Limited Aligner Treatment: Limited treatment may be recommended by the Practice to treat cases that have a minimal amount of correction needed (e.g., treatment limited to the social teeth). This treatment option may not include bite correction or other comprehensive changes. Limited aligner treatment may not fully correct and/or treat all orthodontic needs, and the Practice may recommend further comprehensive treatment at an additional cost. The patient and/or the patient's responsible party/authorized representative should discuss with the Practice to ensure a full understanding of the benefits and risks of this limited treatment option.

Additional Treatment: Growth changes, periodontal inflammation, gingival recession, and tooth or jaw discomfort can be unpredictable. The Practice will consult with the patient and/or the patient's responsible party/authorized representative if further treatment and associated fees are required.

X-ray and Records Consent: I hereby consent to the making of diagnostic records, including x-rays, before, during, and following orthodontic treatment provided by the doctor(s) and their team (where appropriate) for orthodontic treatment prescribed by the doctor(s) for the below individual. I have been informed of, and fully understand, the risks associated with the treatment.

Whitening Treatment: Whitening treatment may be offered or recommended by the Practice at the patient's discretion. There may be risk associated with whitening treatment, including but not limited to, tooth sensitivity which is normal and is usually mild, but it can be worse in susceptible individuals. Usually, tooth sensitivity or pain following a whitening treatment subsides after a few days but it may persist for longer periods of time in susceptible individuals. People with existing sensitivity, recession, exposed dentin, exposed root surfaces and large wear facets, damaged or missing enamel, cracked teeth, cavities, leaking fillings or other dental conditions that cause sensitivity or allow penetration of the gel into the tooth may find that those conditions increase or prolong tooth sensitivity or pain after whitening treatment. Whitening treatment results may vary or regress due to a variety of circumstances. Teeth with multiple colorations, bands, splotches or spots due to tetracycline use or fluorosis do not whiten as well and may need, multiple treatments or may not whiten at all. Results of my whitening treatment cannot be guaranteed. Whitening treatment results are not intended to be permanent. Repeated take-home treatments may be needed to maintain the achieved tooth shade. After whitening treatment, any foods or liquids that could discolor teeth should be avoided such as coffee, teas, soda, tobacco, products, red wine, and red sauces. Whitening is not recommended for patients who do not have all permanent teeth or pregnant/lactating women.

By signing below, I hereby acknowledge and agree that I have been informed of, read and fully understand the above risks associated with the orthodontic treatment, and have had the opportunity to ask questions of my doctor(s) and the Practice team. I also understand that there may be additional risks that occur less frequently than those presented above, and that actual results of treatment may differ from anticipated results.

Informed Consent for Treatment

Signature of Patient or Patient's Authorized Representative

Date:

Print Patient Name Print Relationship Name(if signed by person other than Patient) Relationship (if signed by person other than Patient)