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Patient Information
Person Responsible for Account (must be present at the appointment)

Patient is the person responsible for the account

YesNo
Emergency Contact Information
Authorized Persons

By signing below, you authorize us to discuss your medical and/or financial records with the persons listed.

Insurance Information

Dental Insurance

Medical Insurance

Payment Policies

Payment is due at the time of service unless alternative arrangements have been made in advance.

Returned Checks

Personal checks that are returned due to "insufficient funds" are subject to a $30.00 service fee.

Minors

Adult patients are responsible for full payment at time of service. The adult accompanying a minor is responsible for payment.This office will not bill a non-custodial parent for services delivered to a minor. For unaccompanied minors, treatment may bedenied unless charges have been pre-approved to a credit card or other payment arrangements have been made.

Medical History

Accurate and complete disclosure of medical information is necessary for proper diagnosis and to help prevent any unnecessarycomplication during your treatment. Please mark any condition that you have currently or have been treated for in the past.

Cardiovascular (Heart)

High blood pressureYesNo
Heart attackYesNo
Angina (chest pain)YesNo
Congestive heart failureYesNo
Irregular heart beat (ie A-fib, SVT)YesNo
Cardiac pacemaker or defibrillatorYesNo
Heart murmurYesNo
Mitral valve prolapseYesNo
Damaged heart valveYesNo
Heart valve replacementYesNo
Endocarditis (heart infection)YesNo
Congenital heart defectYesNo
High cholesterolYesNo

Endocrine

DiabetesYesNo
Takes insulin?YesNo
Thyroid diseaseYesNo
HypoglycemiaYesNo

Gastrointestinal

GERD (acid reflux)YesNo
Chron's diseaseYesNo
UlcersYesNo
Hiatal herniaYesNo
HepatitisYesNo
CirrhosisYesNo

Hematologic (blood disorders)

AnemiaYesNo
Sickle cell anemiaYesNo
HemopheliaYesNo
Von Willebrands diseaseYesNo
Taking blood thinners (e.g., Coumadin, Plavix, aspirin)YesNo

Immunologic

History of cancerYesNo
History of chemotherapyYesNo
History of radiation therapyYesNo
HIV/AIDSYesNo
Lyme DiseaseYesNo
LupusYesNo
Sjogrens syndromeYesNo
Rheumatoid arthritisYesNo

Musculoskeletal

Osteoporosis/OsteopeniaYesNo
Do you take or have you ever taken bisphosphonates (e.g., Fosamax, Actonel, Zometa)YesNo
Joint replacementYesNo
FibromyalgiaYesNo
Malignant hyperthermiaYesNo
TMJ / facial painYesNo

Neurological / Psychiatric

Migraine headacheYesNo
Stroke / TIAYesNo
AneurysmYesNo
SeizuresYesNo
Fainting / dizzy spellsYesNo
Multiple sclerosisYesNo
Parkinson's diseaseYesNo
Dementia / Alzheimers diseaseYesNo
AutismYesNo
BipolarYesNo
Depression / AnxietyYesNo

Renal (Urinary)

Renal failure / dialysisYesNo
Kidney stonesYesNo
OtherYesNo

Respiratory

AsthmaYesNo
Chronic bronchitisYesNo
EmphysemaYesNo
TuberculosisYesNo
Chronic sinusitisYesNo
Seasonal allergiesYesNo
Sleep apnea / excessive snoringYesNo

Vision

GlaucomaYesNo
Wear contact lensesYesNo

Women only

PregnantYesNo
Last menstrual period:
Breast feedingYesNo
Breast feedingYesNo
Past Surgical History/Hospitalizations

Please list any past surgeries or hospitalizations and dates:

Medications

Please list any medications you are taking (to also include over the counter and herbals):

Allergies

Please list any medication allergies and the type of reaction:

Miscellaneous
Latex allergyYesNo
History of adverse reaction to general anesthesia/sedationYesNo
History of adverse reaction to local anestheticsYesNo
Social History
Smoke cigarettes/cigarsYesNo
Smokeless tobaccoYesNo
Alcohol useYesNo
DailyYesNo
Weekends/SocialYesNo
RareYesNo
Illicit drug use (i.e., IV drugs, cocaine, marijuana, narcotics)YesNo
Other Medical Conditions Not Listed Above

Please list any other medical conditions:

Is there anything you would like to discuss privately with the doctor?YesNo
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 the following carefully.

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medicalrecords and other individually identifiable health information used or disclosed by us in any form, whether electronically, onpaper, or orally, are kept properly confidential. The Act gives you, the patient, significant new rights to understand and control how your information is used. HIPAA provides penalties for covered entities that misuse personal health information.

As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

We may use and disclose your medical records for several purposes, including treatment, payment, defense of legal matters, to family and friends, and health care operations:

  • Treatment includes providing, coordinating, and/or managing health care related services by one or more health careproviders. An example of this would include teeth cleaning services.Payment includes such activities as obtaining reimbursement for services, confirming coverage, billing or collectionactivities, and utilization review. An example of this would be sending a claim for your visit to your insurance company for payment.
  • Health care operations include the business aspects of running our practice, such as conducting quality assessment andimprovement activities, auditing functions, cost-management analysis, and customer service. An example would be aninternal quality assessment review. We may also create and distribute de-identified health information by removing allreferences to individually identifiable information.
  • To Your Family and Friends: We may disclose your health information to a family member, friend, or other person to theextent necessary to help with your healthcare or with payment for your healthcare. Before we disclose your healthinformation to these people, we will provide you with an opportunity to object to our use or disclosure. If you are notpresent, or in the event of your incapacity or an emergency, we will disclose your medical information based on ourprofessional judgment of whether the disclosure would be in your best interest. We may use our professional judgmentand our experience with common practice to make reasonable inferences of your best interest in allowing a person topick up filled prescriptions, medical supplies, X-rays, or other similar forms of health information. We may use or discloseinformation about you to notify or assist in notifying a person involved in your care, of your location and general condition.

In some limited situations, the law allows or requires us to use/disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:

  • When a state or federal law mandates that certain health information be reported for a specific purpose
  • For public health purposes, such as contagious disease reporting, investigation or surveillance, and notices to and fromthe federal Food and Drug Administration regarding drugs or medical devices
  • Disclosures to governmental authorities about victims of suspected abuse, neglect, or domestic violence
  • Uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare orMedicaid; or for investigation of possible violations of health care laws
  • Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts oradministrative agencies
  • Disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be avictim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else
  • Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors toaid in burial; or to organizations that handle organ or tissue donations
  • Uses or disclosures for health-related research
  • Uses and disclosures to prevent a serious threat to health or safety
  • Uses or disclosures for specialized government functions, such as for the protection of the president or high-rankinggovernment officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health ofmembers of the foreign service
  • Disclosures of de-identified information
  • Disclosures relating to worker's compensation programs
  • Disclosures of a "limited data set" for research, public health, or healthcare operations
  • Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures
  • Disclosures to "business associations" who perform healthcare operations for our office and who commit to respect theprivacy of your health information

We may contact you to provide appointment reminders or information about treatment alternatives or other health-relatedbenefits and services that may be of interest to you. If you wish to be omitted from any mailings please provide a written notice.Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writingand we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

  • The right to request restrictions on certain uses and disclosures of protected health information, including those related todisclosures to family members, other relatives, close personal friends, or any other person identified by you. We are,however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
  • The right to reasonable requests to receive confidential communications of protected health information from us byalternative means or at alternative locations.
  • The right to inspect and copy your protected health information.
  • The right to amend your protected health information.
  • The right to receive an accounting of disclosures of protected health information.
  • The right to obtain a paper copy of this notice from us upon request.

We are required by law to maintain the privacy of your protected health information and provide you with notice of our legalduties and privacy practices with respect to protected health information.

This notice is effective as of January 3, 2017, and we are required to abide by the terms of the Notice of Privacy Practicescurrently in effect.

We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effectivefor all protected health information that we maintain. We will post and you may request a written copy of a revised Notice ofPrivacy Practices from this office.

If you think that we have not properly respected the privacy of your health information or that your privacy protections havebeen violated, you have the right to file a written complaint to us or the U.S. Department of Health and Human Services, Officefor Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliateagainst you for filing a complaint.

For more information about HIPAA and/or to file a complaint, please call or visit or office or contact:The U.S. Department of Health & Human Services, Office for Civil Rights

200 Independence Avenue, S.W.
Washington D.C. 20201
(202) 619-0257 Toll Free: 1-877-696-6775

Authorization

I hereby authorize payment directly to Bluhm, Dorsch, and Vandervort, P.C. of the group insurance benefits otherwise payableto me. I authorize the use of this form on all my insurance submissions and I authorize the release of information to all myinsurance companies. I understand that I am responsible for my bill. I authorize Bluhm, Dorsch and Vandervort, P. C. to act asmy agent in helping me to obtain payment from my insurance companies. I permit a copy of this authorization to be used inplace of the original. I give Bluhm, Dorsch and Vandervort, P. C., its employees, and/or other agents express prior consent tocontact me at any/all phone numbers, including cell numbers (by phone call or text message) and email addresses, for thepurpose of appointments, treatment, insurance, or payment.I confirm that all information on this patient registration form is correct to the best of my knowledge.

HIPAA Patient Consent Form
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