Last First MI




4. MEDICAL HISTORY continued
Have you ever had any of the following diseases or medical problems? What are the main concerns that you would like orthodontics to accomplish?

Patient Consent for use and Disclosure of Protected Health Information

With my consent, Sierra Orthodontics, may use and disclose my/ my child's protected health information to carry out treatment, payment and healthcare operations.
Please refer to Sierra Orthodontics Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent.
Sierra Orthodontics reserves the right to revise its Notice of Privacy Practice at any time.

With my consent, the office may call my home or other designated locations and leave a message on voice mail or to the person who answers in reference to any items that assist treatment, such as appointment reminders, insurance items, financial questions and any call pertaining to my clinical care including laboratory results.

With my consent, the office may mail to my home or other designated location any items that assist the practice, such as appointment reminder cards and patient statements.

With my consent, the office may share treatment care and results with the person that accompanies my child to the orthodontic appointment.

In the case of dual guardianship, both guardians may be contacted about the patient's appointments, treatment progress, and financial information. However, the office will not share either guardian's phone numbers, social security numbers or addresses with the other guardian. Only the patient's information will be shared.

By signing this form, I am consenting to Sierra Orthodontics use and disclosure of my/ my child's personal Health Information needed to carry out treatment.

Consent for Electronic Communication

Unencrypted email is not a secure form of communication. There is some risk that any individually identifiable health information and other sensitive or confidential information that may be contained in such email may be misdirected, disclosed to or intercepted by, unauthorized third parties. However, you may consent to receive email from us regarding your treatment. We will use the minimum necessary amount of protected health information in any communication. Our first email to you will verify the email address you provide.

If this office accepts insurance, I understand that I am responsible for payment of services renderedand also responsible for paying any co-payment and deductibles that my insurance does not cover. I herby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office.