dr. hirschinger’s new patient registration information · how likely are you to doze off or fall...

Dr. Hirschinger’s New Patient Registration Information Please check the box to the left of the text to respond to the question

Date: ___________________ First name: _____________ Last name: ___________________ Middle initial: ___ Preferred name: _________________ Address: ____________________________________________ City: ___________________ State: ____ Zip: _________ Home phone: ____________ Cell phone: ____________ Email address: _______________________________________ Date of birth: __________________ Social security #: ____________________Driver’s license #: ___________________ Gender: Male Female Marital status: Single Married Divorced Separated Widowed Height: ______ feet ______ inches Weight: ______ pounds Waist: ______ inches Neck: ______ inches Have there been any significant changes in your weight in the past year? No Yes Intended Unintended

Gain Loss Number of pounds ______ Are you? Left handed Right handed Occupation: ________________________________________________ Pharmacy: We use electronic prescriptions so if you have a preferred pharmacy, please provide the following: Pharmacy name: ________________________ Pharmacy phone number: ____________ Pharmacy zip code: ________ Emergency contact: First name: _____________ Last name: ______________________________ Phone: ____________ Referral information: How did year hear about Dr. Hirschinger? Referred by doctor Referred by friend/family

Internet Other Name of referral or search term used: _______________________________________________ Reminders: How do you want to be reminded of your appointments? Check all that apply: Text Email Phone Are you? Employed Unemployed Homemaker Retired Student What is your occupation? _____________________________________________________________________________ What is the highest level of school that you completed? High school College Masters Doctorate What is your religion (optional)? ________________________ Do you have religious beliefs regarding your treatment that I need to be aware of? No Yes (please describe) __________________________________________________________________________________________________

Primary medical insurance: We do not accept assignment of insurance but we will submit your insurance for you and the insurance company will reimburse you. If you want us to submit your information to your insurance company, please provide the following information.

Name of Insured: First name: _____________ Last name: ____________________________ Middle initial: ___________ Relationship to Insured: Self Spouse Child Other ___________________ Insured social security #: ______________ Insured date of birth: ___________________ Employer: _________________________________________________________________________________________ Address: ____________________________________________ City: ___________________ State: ____ Zip: _________ Insurance company: _________________________________________________________________________________ Address: ____________________________________________ City: ___________________ State: ____ Zip: _________

Secondary medical insurance: Name of Insured: First name: _____________ Last name: ____________________________ Middle initial: ___________ Relationship to Insured: Self Spouse Child Other ___________________ Insured social security #: ______________ Insured date of birth: ___________________ Employer: _________________________________________________________________________________________ Address: ____________________________________________ City: ___________________ State: ____ Zip: _________ Insurance company: _________________________________________________________________________________ Address: ____________________________________________ City: ___________________ State: ____ Zip: _________

Patient Medical History Please check the box to the left of the text to respond to the question

First Name: _______________________ Last Name: _____________________________ Middle Initial: ______________ Are you under a physician’s care now? No Yes (please explain) ____________________________________________________________________________________________________________________________________________________________________________________________________ Are you allergic to any of the following? Acrylic Antibiotics Aspirin Codeine Latex Local anesthetic

Metals Other (please explain and list any other allergies) __________________________________________________________________________________________________ Do you have, or have you ever had, any of the following?

AIDS/HIV positive Cortisone medicine Hemophilia Radiation treatment Alzheimer's disease Diabetes Hepatitis A Recent weight loss Anaphylaxis Drug addiction Hepatitis B or C Renal dialysis Anemia Easily winded Herpes Rheumatic fever Angina Emphysema High blood pressure Rheumatism Arthritis/Gout Epilepsy or seizures High cholesterol Scarlet fever Artificial heart valve Excessive bleeding Hives or rash Shingles Artificial joint Excessive thirst Hypoglycemia Sickle cell disease Asthma Fainting spells/Dizziness Irregular heartbeat Sinus trouble Blood disease Frequent cough Kidney problems Spina bifida Blood transfusion Frequent diarrhea Leukemia Stomach/intestinal disease Breathing problem Frequent headaches Liver disease Stroke Bruise easily Genital herpes Low blood pressure Swelling of limbs Cancer GERD/acid reflux Lung disease Thyroid disease Chemotherapy Glaucoma Mitral valve prolapse Tonsillitis Chest pains Hay fever Osteoarthritis Tuberculosis Cold sores/Fever blisters Heart attack/Heart failure Osteoporosis Ulcers Congenital heart disorder Heart murmur Pain in jaw joints Tumors or growths Convulsions Heart pacemaker Parathyroid disease Venereal disease

Heart trouble/Disease Psychiatric care Yellow jaundice Have you ever had any serious illness not listed above or currently have a scheduled medical procedures No Yes Please provide any additional information below that Dr. Hirschinger needs to understand your general medical condition that is unrelated to your pain. Questions regarding your pain will be asked on other pages. __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Women: Are you pregnant? No Yes Are you nursing? No Yes Are you taking birth control? No Yes Medication______________________ Dose______ When did you start taking it?________________________________ Other birth control in the past? No Yes Medication ______________________ Dose_____ How long? _________

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the office of any changes in medical status. _____________________________________________________ Signature of patient or patient representative PATIENT PARENT GUARDIAN Name (if parent or guardian)__________________________________________________Date: ____________________

Dr. Hirschinger’s Pain Questionnaire Please check the box to the left of the text to respond to the question

What do you think is causing your pain? TMJ Migraines Other headache Muscle pain Nerve pain Sleep apnea Don’t know Other (please explain) _________________________________________________

How many different pains do you have? 1 2 More than 2 If you have more than one pain, are they independent (two separate pains even though they may sometimes occur at the same time) or dependent (almost always happen together, one spreads or causes the other)? What is the main reason you need to see Dr. Hirschinger? __________________________________________________________________________________________________ __________________________________________________________________________________________________ Where does it hurt? Check all that apply Left Right Both sides Upper teeth Lower teeth Jaw

Chin Cheek Ear Temple Neck Eye Nose Forehead Back of head Top of head Inside the mouth Other Please explain ___________________________________________________________

Is there anything visually unusual in your appearance as a result of this pain? No Yes (please explain) __________________________________________________________________________________________________ When did the pain start? _____________________________________________________________________________ Was there anything that occurred that caused this pain to start? Fall Accident Medical procedure

Dental procedure It started on its own I don’t know Other (please explain) __________________________________________________________________________________________________ How would you describe your pain? Check all that apply

Shooting Sharp Electrical Hot Burning Radiating Itchy Cold Numb Sensitive Tingling Aching Heavy Dull Cramping Throbbing

Using a 0-10 scale with 0 = no pain and 10 = the most intense pain you could ever imagine, please answer the following: What is the highest amount of pain you feel? 1 2 3 4 5 6 7 8 9 10 What is the lowest amount of pain you feel? 1 2 3 4 5 6 7 8 9 10 What is the average amount of pain you feel? 1 2 3 4 5 6 7 8 9 10 How long does your pain last? Seconds Minutes Hours Days Weeks Months Years Constant pain does not change or vary like the ocean horizon. Continuous pain is always there but it varies like the waves in an ocean. Intermittent pain can completely disappear like the sunset. Is your pain ? Constant Continuous or Intermittent Is there anything you can do to make your pain better? No Yes (please explain) __________________________________________________________________________________________________ Is there anything you can do to make your pain worse? No Yes (please explain) __________________________________________________________________________________________________ Are there any other symptoms that you have that are associated with this pain such as Tingling Tightness in neck

Numbness Confusion Thirst Dry mouth Excessive tiredness Shoulder muscles Other Please explain ______________________________________________________________________________________ Are there any other associated pains that you have? No Yes (please explain) __________________________________________________________________________________________________ Is there anything you can do to trigger this pain? No Yes (please explain) __________________________________________________________________________________________________

Have you seen a dentist for your pain? No Yes Has a dentist ever adjusted your teeth to try to reduce your pain? No Yes Did it help? No Yes Has a dentist planned/provided any dental treatment to treat your pain? No Yes If Yes, what was planned/provided? __________________________________________________________________________________ Are you currently taking any medication for this pain? No Yes If Yes, please list the medications you take Medication Dose Explain why you take it, times taken per day, and when you started 1. ______________________ ___________ ___________________________________________________________ 2. ______________________ ___________ ___________________________________________________________ 3. ______________________ ___________ ___________________________________________________________ 4. ______________________ ___________ ___________________________________________________________ Have you tried other medication in the past for this pain? No Yes If Yes, please list the medications you tried Medication Dose Explain why you took it, times taken per day, and how long you took it 1. ______________________ ___________ ___________________________________________________________ 2. ______________________ ___________ ___________________________________________________________ 3. ______________________ ___________ ___________________________________________________________ 4. ______________________ ___________ ___________________________________________________________ Do you take other medication for any other reason? No Yes If Yes, please list the medications you take Medication Dose Explain why you take it, times taken per day, and when you started 1. ______________________ ___________ ___________________________________________________________ 2. ______________________ ___________ ___________________________________________________________ 3. ______________________ ___________ ___________________________________________________________ 4. ______________________ ___________ ___________________________________________________________ 5. ______________________ ___________ ___________________________________________________________ 6. ______________________ ___________ ___________________________________________________________ 7. ______________________ ___________ ___________________________________________________________ 8. ______________________ ___________ ___________________________________________________________ 9. ______________________ ___________ ___________________________________________________________ Have you had any imaging done for your pain? No Yes If Yes, what was taken? X-rays CT’s MRI’s Please list who prescribed the imaging, when it was taken, and if you have a copy of the imaging and/or report. __________________________________________________________________________________________________ __________________________________________________________________________________________________ Do you have an attorney in regard to this pain? No Yes If you do not have an attorney, do you plan to hire an attorney in regard to this pain? No Yes If you have an attorney, or plan to hire one, please explain what the legal issues are. __________________________________________________________________________________________________

Questions about your sleep How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling just tired? Use the following scale to choose the most appropriate number for each situation: 0 = would never doze; 1 = Slight chance of dozing; 2 = Moderate chance of dozing; 3 = High chance of dozing Situation Chance of dozing Sitting and reading 0 1 2 3 Watching TV 0 1 2 3 Sitting, inactive in a public space (e.g. a theatre or a meeting) 0 1 2 3 As a passenger in a car for an hour without a break 0 1 2 3 Lying down to rest in the afternoon when circumstances permit 0 1 2 3 Sitting and talking to someone 0 1 2 3 Sitting quietly after a lunch without alcohol 0 1 2 3 In a car, while stopped for a few minutes in the traffic 0 1 2 3 Total the # of points ______ Do you snore? No Yes Have you been told by others that you snore? No Yes Do you ever wake up gasping for air? No Yes Has anyone said that you stop breathing at night? No Yes Have you been told you have sleep apnea? No Yes Do you have insomnia? No Yes When you wake up in the morning do you feel like you had a good night’s sleep? No Yes Have you ever had an overnight sleep study? No Yes If Yes, please list the date of the study, and doctor who prescribed the study _________________________________________________________________________________ Do you take anything to help you sleep? No Yes If Yes, what do you take, and what is the dose? __________________________________________________________________________________________________Do you use, or been advised to wear, a CPAP mask or device? No Yes If Yes, how often do you wear it?

Every night Most nights Some nights Rarely Never If you don’t you wear it every night, explain why __________________________________________________________________________________________________ Do you use, or been advised to wear, an oral appliance for sleep apnea? No Yes If Yes, how often do you wear it?

Every night Most nights Some nights Rarely Never If you don’t you wear it every night, explain why __________________________________________________________________________________________________ Do you have to get up during the night to urinate? No Yes If yes, how many times? 1 2 3 or more Social questions Do you feel you usually eat…? Too much Too little About right What foods do you eat for your typical diet? Hard Soft Crunchy Chewy Salads Raw vegetables

Steak Hard breads Other ____________________________________________________________________ Do you drink alcohol? No Beer Wine Spirits How many alcoholic drinks do you have in a typical week? 1 2 3-4 5-7 More than 7 Do you drink coffee or other drinks with caffeine? No Yes How many drinks with caffeine do you have in a typical day? 1 2 3 4 5 or more Do you use tobacco products? No Cigarettes Cigars Pipes Number of Cigarettes per day _______ Cigars per day _______ Pipes per day _______ How long have you been smoking? Cigarettes _____ years Cigars _____ years Pipes _____ years Do you use chewing tobacco? No Yes If Yes, how long have you been chewing tobacco? _____ years Do you use recreational drugs? No Yes If Yes, what do you use, and how often do you use it? __________________________________________________________________________________________________ Have you ever been treated for an addiction? No Yes If Yes, what were you treated for? __________________________________________________________________________________________________

Questions about your jaw and teeth How often do you see your general dentist? 3 months 4 months 6 months 12 months Not regular Is there any current dental treatment planned? No Yes If Yes, what treatment needs to be done? __________________________________________________________________________________________________ How often do you brush your teeth? Everyday Most days Some days Rarely Never How often do you floss your teeth? Everyday Most days Some days Rarely Never Do you chew gum? No Yes If Yes, how many pieces a day do you chew, and for how long? __________________ Do you have pain when you chew food? No Left Right Both sides Do you bite your nails? No Yes Do you chew on ice, pens, pencils, or other objects? No Yes Do you clench your teeth during the day? No Yes Do you think you clench your teeth when you sleep? No Yes Do you think you grind your teeth when you sleep? No Yes Have you ever been told you have TMJ? No Yes Does your jaw pop or click? No Left Right Both sides If Yes, when did it start making noise? __________________________________________________________________________________________________ When it pops or clicks is there any pain? No Left Right Both sides Do you ever hear or feel a grinding, grating type of sound when you open and/or close your mouth? No Yes Do you have pain when you hear or feel a grinding sound? No Left Right Both sides Has your jaw ever prevented you from opening your mouth? No Left Right Both sides (please describe) __________________________________________________________________________________________________ Has your jaw ever prevented you from closing your mouth? No Left Right Both sides (please describe) __________________________________________________________________________________________________ Do you wear an oral appliance that fits over your teeth? No Yes If you do wear an oral appliance, please answer the following questions: The appliance is Soft Hard The appliance fits on the Upper teeth Lower teeth The appliance covers Only the front teeth Only the back teeth All of my teeth Do you wear the appliance during the day? Everyday Most days Some days Rarely Never Do you wear the appliance every night? Every night Most nights Some nights Rarely Never If you don’t you wear it every night, explain why __________________________________________________________ How long have you worn an appliance? _________________ Has the appliance changed your bite (the way your teeth meet)? No Yes How many appliances have you had? ___________________________________________________________________

Family and mental health questions Do you have any children? No Yes If you do, please list their gender, their age, and if they live at home Child 1 Male Female Age ____ Living at home Child 2 Male Female Age ____ Living at home Child 3 Male Female Age ____ Living at home Child 4 Male Female Age ____ Living at home Child 5 Male Female Age ____ Living at home Child 6 Male Female Age ____ Living at home Biological Mother Living Current age or age at death _____ Cause of death ______________________________ Biological Father Living Current age or age at death _____ Cause of death ______________________________

Sister Brother Living Current age or age at death _____ Cause of death ______________________________ Sister Brother Living Current age or age at death _____ Cause of death ______________________________ Sister Brother Living Current age or age at death _____ Cause of death ______________________________ Sister Brother Living Current age or age at death _____ Cause of death ______________________________ Sister Brother Living Current age or age at death _____ Cause of death ______________________________ Sister Brother Living Current age or age at death _____ Cause of death ______________________________

Have you had any counseling? No Marriage counselor Psychologist Psychiatrist Hypnotist Cognitive behavior therapist Other (please explain) __________________________________________________

Do you take any psychiatric medication? No Yes If Yes, please list the medication below. Medication Dose Times taken per day, who prescribed, and why the medication is taken 1. ______________________ ___________ ___________________________________________________________ 2. ______________________ ___________ ___________________________________________________________ 3. ______________________ ___________ ___________________________________________________________ 4. ______________________ ___________ ___________________________________________________________ Have you ever thought of suicide? No Yes If you did, do you have a Plan Intent Means? (please describe) ____________________________________________________________________________________ Do you have any mental health issues? Depression Anxiety Schizophrenia Bi-polar ADHD Other (please describe) ____________________________________________________________________________________ Is there any history of family abuse? Physical Sexual Emotional (please describe) __________________________________________________________________________________________________ Do you have a good support system? No Yes (If No, please describe why) __________________________________________________________________________________________________ Have you suffered any head Injuries? No Yes (please describe) __________________________________________________________________________________________________ Have you suffered any neck Injuries? No Yes (please describe) __________________________________________________________________________________________________ Have you been in any auto accidents? No Yes (please describe) __________________________________________________________________________________________________ Have you suffered any chronic illnesses? No Yes (please describe) __________________________________________________________________________________________________ Have you had any major surgeries? No Yes (please describe) __________________________________________________________________________________________________ __________________________________________________________________________________________________ Have you had any type of plastic surgery including Botox, or dermal fillers? No Yes (please describe) __________________________________________________________________________________________________ Have you ever been treated in the emergency room for any reason? No Yes (please describe) __________________________________________________________________________________________________

Do you have any social stressors such as at work? No Yes (please describe) __________________________________________________________________________________________________ Do you have any personal stressors such as at home? No Yes (please describe) __________________________________________________________________________________________________ Do you have any financial stressors? No Yes (please describe) __________________________________________________________________________________________________ Are you involved in taking care of someone with special needs, infirmed, or aged? No Yes (please describe) __________________________________________________________________________________________________ Have you ever experienced a panic attack? No Yes Do you exercise? No Yes If Yes, how many times per week? 1 2 3-‐4 5-‐6 7 Do you? Walk Run Bicycle Swim Lift weights Yoga Pilates Dance Other (please describe) ____________________________________________________________________________________ What type of pain tolerance do you think you have? Low Normal High If there is anything else you want to add that has anything to do with this pain or your overall medical history that has not been asked in any of the questions, please enter it in the area below. __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________

Dr. Hirschinger’s Headache Questionnaire Please check the box to the left of the text to respond to the question

Do you suffer from headaches? No Yes If No, please skip the three headache questionnaires How many different headaches do you have? One Two Three Headache 1 – please complete one form for each separate headache How many of these types of headaches have you had in your life? _______ Is this the worst headache you have ever had? No Yes Did the headache appear suddenly? No Yes Do you have a previous history of headaches? No Yes Is this different than previous ones? No Yes Do you have any of the following? Numbness Loss of consciousness Confusion Fever Weight loss How long do the headaches last if you do not take medication? Seconds Minutes Hours Days Weeks

Months Years If the headaches last seconds or minutes, how many do you get a day? ____________________ Is the headache pulsating and/or throbbing? No Yes Does it occur on? Left side Right side Both sides Does it ever change sides? No Yes The headache pain is Mild Moderate Severe Does the headache occur, or get worse, with? Coughing Exertion Lying down Sex Standing Does the headache cause Sensitivity to light Sensitivity to sound Nausea Vomiting Agitation Do you want to go into a dark quiet room and go to sleep when you get the headache? No Yes Have you ever missed work or school because of the headache? No Yes Before you get the headache, do you get any sense that the headache is coming on? No Yes If Yes, do you sense

Blind spots Flashing lights Nausea Weakness on one side Numbness or tingling on one side Excessive yawning Other (please describe) _________________________________________________________

Is there something that can trigger the headache such as a smell, something that you eat, drink, etc.? No Yes If Yes, what are the triggers? __________________________________________________________________________ Where do you feel the headache? Check all that apply Upper teeth Lower teeth Neck Chin Forehead

Cheek Ear Temple Jaw Eye Nose Back of head Top of head Other (please describe) __________________________________________________________________________________________________ Do you get any of the following symptoms appearing on the same side of the head where you get the headache?

Drooping eyelid Pupil constriction Redness of the whites of the eyes Tearing Runny nose Facial blushing Swelling Sweating

Does the headache feel like? Stabbing Ice picks Tight band around your head How often does this headache occur per month? _________________________________________________________ When does the headache occur? I wake up with it Morning Afternoon Evening During sleep As the day progresses, does the headache get? Better Worse Stays the same Have you seen a doctor(s) for this headache? No Yes If Yes, how many, and what type of doctor were they? __________________________________________________________________________________________________ Did you feel they helped you with your headache? No Yes Do you take medication for this headache? No Yes If Yes, please list the medication(s) below Medication Dose Times taken per day, and who prescribed the medication 1. ______________________ ___________ ___________________________________________________________ 2. ______________________ ___________ ___________________________________________________________ 3. ______________________ ___________ ___________________________________________________________ Were previous tests or imaging done? No Yes If Yes, what was done and what was the diagnosis, if you know? __________________________________________________________________________________________________ Women: Does the headache occur within two days of your menses? No Yes

Headache 2 – please complete one form for each separate headache or skip if you do not have any headaches How many of these types of headaches have you had in your life? _______ Is this the worst headache you have ever had? No Yes Did the headache appear suddenly? No Yes Do you have a previous history of headaches? No Yes Is this different than previous ones? No Yes Do you have any of the following? Numbness Loss of consciousness Confusion Fever Weight loss How long do the headaches last if you do not take medication? Seconds Minutes Hours Days Weeks







Headache 3 – please complete one form for each separate headache or skip if you do not have any headaches How many of these types of headaches have you had in your life? _______ Is this the worst headache you have ever had? No Yes Did the headache appear suddenly? No Yes Do you have a previous history of headaches? No Yes Is this different than previous ones? No Yes Do you have any of the following? Numbness Loss of consciousness Confusion Fever Weight loss How long do the headaches last if you do not take medication? Seconds Minutes Hours Days Weeks







Please list all your health care providers (physicians, dentists, physical therapist, psychiatrist, psychologist, chiropractor, acupuncturist, massage therapists, etc.). Provider’s name: __________________________________________ Specialty: _________________________________ Address: ____________________________________________ City: ___________________ State: ____ Zip: _________ Office phone #: __________________________________ Fax #: _____________________________________________ Did this person provide treatment for your current condition? No Yes Did it help? No Yes (please explain) __________________________________________________________________________________________________ Do you want Dr. Hirschinger to send a report to this provider? No Yes (if No, please explain) __________________________________________________________________________________________________ Provider’s name: __________________________________________ Specialty: _________________________________ Address: ____________________________________________ City: ___________________ State: ____ Zip: _________ Office phone #: __________________________________ Fax #: _____________________________________________ Did this person provide treatment for your current condition? No Yes Did it help? No Yes (please explain) __________________________________________________________________________________________________ Do you want Dr. Hirschinger to send a report to this provider? No Yes (if No, please explain) __________________________________________________________________________________________________

Provider’s name: __________________________________________ Specialty: _________________________________ Address: ____________________________________________ City: ___________________ State: ____ Zip: _________ Office phone #: __________________________________ Fax #: _____________________________________________ Did this person provide treatment for your current condition? No Yes Did it help? No Yes (please explain) __________________________________________________________________________________________________ Do you want Dr. Hirschinger to send a report to this provider? No Yes (if No, please explain) __________________________________________________________________________________________________




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 IT CAREFULLY.

The Health and Insurance Portability & Accountability Act of 1996 (HIPAA) requires all health care records and other individually identifiable health information used or disclosed to us in any form, whether electronically, on paper, or orally, to be kept confidential. This federal law gives entities that misuse personal health information. As required by law, 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.

Without specific written authorization, we are permitted is use and disclose your health care records for the purpose of treatment, payment, and health care operations.

Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. For example, we may need to share information with other health care providers or specialist’s involved n the continuation of your care.

Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. For example, we may disclose treatment information when billing a medical and/or dental plan for your medical and/or dental services.

Health Care Operations include the business aspects of running our practice. For example, patient information may be used for training purposes, or quality assessment.

Unless you request otherwise, we may use or disclose health information to a family member, friend, personal representative, or other individual to the extent necessary to help with your health care or with payment for your health care. In the event of an emergency or your incapacity, we will use our professional judgment in disclosing only the protected health information necessary to facilitate needed care. In addition, we may use your confidential information to remind you of appointments by sending reminder postcards and/or leaving messages at home and/or work. Your protected health information may also be used by our office to recommend treatment alternatives or to provide you with information about health related benefits and services that may be of interest to you. In addition, we may disclose your health information for public health oversight activities, judicial or administrative proceedings, in response to a subpoena or court order, to military authorities of Armed Forces personnel, to federal officials for lawful intelligence, counterintelligence, and other national security activities, to correctional institutions or law enforcement officials, and/or to report suspected abuse, neglect, or domestic violence. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that request, except to the extent that we have already taken actions relying on your authorization. You have certain rights in regards to your protected health information, which may exercise by presenting a written request to our Privacy Officer at the practice address listed below:

The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures 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 request to receive confidential communications of protected health information from us by alternative means or at alternative locations.

The rights to access, inspect, and copy your protected health information, with limited exceptions. A reasonable fee may be assessed. The right to request an amendment to your protected health information. We may deny your request in certain situations. The right to receive an accounting of disclosures of protected health information made outside of treatment, payment, or health care

operations or based on your previous authorizations. The right to obtain a paper copy of this notice from us upon request, even if you have agreed to receive the notice electronically.

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

This notice is effective as of April 14th, 2003 as we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. Revisions to our Notice of Privacy Practices will be posted on the effective date and you may request a written copy of the Revised Notice from this office.

You have the right to file a formal complaint with us at the address below or with the department of health & human Services, Office of Civil Rights, in the event you feel your privacy rights have been violated. We will not retaliate against you for filing a complaint.

Privacy Officer: Rich Hirschinger For more information or to file complaint: Office Name: Rich Hirschinger, DDS, Inc. 877-696-6775 (toll free) 9615 Brighton Way Suite 323 Beverly Hills, CA 90210 Phone: 310.359.9080 Fax: 310.935.3152

Rich Hirschinger, DDS, Inc. 9615 Brighton Way Suite 323, Beverly Hills, CA 90210 310.359.9080

[email protected] www.LoveOFP.com

NOTICE OF PRIVACY PRACTICE

First name: _____________ Last name: ___________________ Date of birth: _____________________________________

As required by the Health Insurance Portability and Accountability Act of 1996 (HIPPA) this office may use your personal health information for the purpose of treatment, payment or health care operations. The specific uses and disclosures that we intend to make are described in our Notice of Privacy Practices. You have the right to review the Notice of Privacy Practices prior to signing the consent form. You may request restrictions on the “restriction request” form, which we will provide if needed. You may revoke this consent at any time by signing and dating the revocation form, which we will provide if needed.

ACKNOWLEDGEMENT / CONSENT OF NOTICE OF PRIVACY PRACTICES

I hereby consent to the use and disclosure of my personal health information for the purposes of treatment, payment and healthcare operations. I also acknowledge that I am informed of “Rich Hirschinger, DDS, Inc.” Practice Privacy Policy and have been offered a copy.

___________________________________________________________ _______________________ Signature of patient or patient representative Date

COMMUNICATION REQUEST

The phone numbers listed below are the only place(s) my personal health information may be left as a message or as voicemail. This includes appointment times, results of testing, insurance status and/or any other personal communication that needs to take place that may contain personal health information and is a part of my healthcare in this office.

Phone number Location (check one)

________________________________ Home Work Cell Phone Other ________________________________ Home Work Cell Phone Other ________________________________ Home Work Cell Phone Other

__________________________________________________________________ __________________________ Signature of patient or patient representative Date

Additional Communication

I give my permission for medical information to be discussed with: Parents (if under 18) Spouse/Partner Other: ______________________

______________________________________________________ _______________________ Signature of patient or representative Date

You can select either “Click to Securely Submit” or “Click to Print.” If you submit the forms, they are securely sent over the Internet and you do not have to do anything else. If you print the forms, you must fax them to

310.359.3152, mail, or bring them with you to your first appointment. Our preference is to have them submitted so that we have the information before you arrive.

dr. hirschinger’s new patient registration information · how likely are you to doze off or fall...

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