Adult Patient Information Hipaa Form

Adult Patient Information

474 Hurffville-Crosskeys Road
Atrium One, Suite A - Sewell, NJ 08080
856-582-1000

Patient Information

Name (last, first, middle):

SS#:

Drive Lic #:

Home #:

Cell #:

Email:

Home Address:

City:

State:

Zip:

Gender: M F

Age:

Date of Birth:

Single Married Widowed Separated Divorced

Patient Employed By:

Occupation:

Business Address:

Business Phone:

Full-Time Student: Yes No

Name of College:

City & State:

How did you hear about us?: Yellow Pages Family

Other

In case of emergency who would be notified?

Phone:

Primay Insurance

Person Responsible for Account (last, first, middle):

Relationship to patient:

Insured's Birthdate:

Insured's SS#:

Address (If different than patient):

Phone #:

City:

State:

Zip:

Person Responsible Employed By:

Occupation:

Business Address:

Business Phone:

Insurance Company:

Contract #:

Group #:

Subscriber #:

Name of other dependents covered under this plan:

Additional Insurance

Patient Covered by Additional Insurance:

Person Responsible for Account (last, first, middle):

Relationship to patient:

Insured's Birthdate:

Insured's SS#:

Address (If different than patient):

Phone #:

City:

State:

Zip:

Person Responsible Employed By:

Occupation:

Business Address:

Business Phone:

Insurance Company:

Contract #:

Group #:

Subscriber #:

Name of other dependents covered under this plan:

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.

Signature of person responsible:

Date:

Dental History

Reason for Today's Visit:

Previous Dentist(s):

Address:

Date of last dental care:

Date of last dental x-rays:

Select any of the following that apply:

Bad Breath

Loose teeth or broken fillings

Sensitivity when biting

Grinding teeth

Sensitivity to sweets

Food collection between teeth

Sensitivity to hot

Clicking or Popping Jaw

Sensivity to cold

Bleeding Gums

Periodontal treatment

Sores or growths in your mouth

Do you like your smile? Yes No

Would you like to have whiter teeth? Yes No

How often do you brush?

How often do you floss?

Have you ever experienced an adverse reaction during or in conjuction with a medical or dental procedure? Yes No

Other information about your dental health or previous treatment:

Medical History

Physician's Name:

Date of Last Visit:

Have you had any serious illnesses or operations? Yes No

If yes, please describe:

Have you ever had a blood transfusion? Yes No

If yes, give approximate dates:

(Woman) Are you pregnant?? Yes No

Nursing? Yes No

Taking birth control pills? Yes No

Select any of the following that apply:

AIDS

Anemia

Arthritis, Rheumatism

Artificial Heart Valves

Artificial Joints, Pins, Screws

Asthma

Back Problems

Blood Disease

Cancer

Chemical Dependency

Chemotherapy

Circulatory Problems

Cortisone treatments

Cough, Persistant

Diabetes

Epilepsy

Fainting

Glaucoma

Headaches

Heart Murmur

Heart Problems

Hemophilia

Hepatitis

High Blood Pressure

HIV Positive

Jaw Pain

Kidney Disease

Liver Disease

Mitral Valve Problems

Nervous Problems

Pacemaker

Psychiatric Care

Radiation Treatment

Respitory Disease

Rheumatic Fever

Scarlet Fever

Shortness of Breath

Skin Rash

S.T.D.

Stroke

Surgery

Swelling of Feet or Ankles

Thyroid Problems

Tobacco

Tonsillitis

Tuberculosis

Ulcer

Other:

Medications

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

Pharmacy Name:

Phone:

Allergies

Aspirin

Barbiturates (Sleeping Pills)

Codeine

Penicillin

Sulfa

Anesthetic

Other:

Signature of person responsible:

Date:

HIPAA

474 Hurffville-Crosskeys Road
Atrium One, Suite A - Sewell, NJ 08080
856-582-1000

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.

Date:

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.

Please print patient's name

Patient Signature (if 18 or older)

Parent / Guardian / Legal Representative Signature

Description of Authority

How do you want to be addressed when summoned from the reception area? First Name Only Proper Sir Name Other

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:

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

Name:

Relationship:

Name:

Relationship:

I AUTHORIZE Contact from this office to confirm my appointments, treatment, and billing information via:

Cell Phone Home Phone Work Phone Text Message My Cell Phone Email Confirmation Any of the Above

I AUTHORIZE Contact from this office to information about my health via:

Cell Phone Home Phone Work Phone Text Message My Cell Phone Email Confirmation Any of the Above

I AUTHORIZE Contact from this office to special services, events, fund raising efforts, or new health info via:

Cell Phone Home Phone Work Phone Text Message My Cell Phone Email Confirmation Any of the Above

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:

It was an emergency treatment

The patient refused to sign

I could not communicate with the patient

The patient was unable to sign because:

Other