Adult Medical Update
474 Hurffville-Crosskeys Road
Atrium One, Suite A - Sewell, NJ 08080
Patient Information
If Any Changes (below):

Medical History
Have you had any serious illnesses or operations?
Have you ever had a blood transfusion?
(Woman) Are you pregnant??
Taking birth control pills?

List any medications being taken: (including aspirin, contraceptive, coumadin)

The above information is accurate and complete to the best of my knowledge. Any errors or omissions in completing this form are solely my responsibility. We reserve the right to charge for appointments cancelled or failed without 24 hours advance notice. Weekdays after 4PM and Saturdays will automatically be charged. Payment is due in full at time of treatment unless prior arrangements have been approved. Balances unpaid after 90 days are subject to a late charge of 1.5% per month, and may be reported to the credit bureaus at our discretion. I understand that by signing below I accept financial responsibility for all charges whether or not paid by insurance.

Washing Township Dental
474 Hurffville-Crosskeys Road
Atrium One, Suite A - Sewell, NJ 08080

HIPAA OMNIBUS RULE - Patient Acknowledgement of Receipt of Notice of Privacy Practices and Consent/limited authorization & release form. You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.

The undersigned acknowledges having had full opportunity to read and consider the contents of this HIPAA Consent form and the Notice of Privacy Practices. The undersigned understands that, by signing this consent form, they are giving consent to use and disclose their protected health information to carry out treatment, payment activities, insurance and any other office procedures. A copy of this signed and dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTORS/FACILITIES IN THE FUTURE.

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide this information with your knowledge and consent.

(This includes step-parents, grandparents, and/or any caretakers who can have access to this patient's records):

I AUTHORIZE Contact from this office to confirm my appointments, treatment, and billing information via:
I AUTHORIZE Contact from this office to information about my health via:
I AUTHORIZE Contact from this office to special services, events, fund raising efforts, or new health info via:

Your comments regarding Acknowledgement or Consents
Office Use Only As privacy officer, I attempted to obtain the pateint's (or representative's) signature on this Acknowledgement, but did not because:
Clear Signature
Accept Signature