new pt paperwork

8/3/2019 New PT Paperwork

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9:55 AM DATE 1/30/

ID: Chart ID:

Is: EH Policy Holder[ | Responsible Party

Responsible Party (if someone other than the patient) -First Name:Addre s s :City, State, Zip:Home Phone: Work Phone:Birth Date: Soc Sec:

PATIENT REGISTRATION

Last Name:Preferred Name:

Last Name:Address 2:

Middle Initial:

Middle Initial:

Ext:Pager:

Cellular:Drivers Lie:

O Responsible Party is also a Policy Holder for Patient O Primary Insurance Policy Holder O Secondary Insurance Policy Holder

State / Zip:

Patient InformationAddress:Ci t y :Home Phone:Sex: QMaleBirth Date:E-mail: _ _

Section 2Employment Status: Q Full Time QPart Time O RetiredStudent Status: Q Full TimeMedicaid ID:

Address 2:Pager:

_Work Phone: Ext: Cellular:O Female Marital Status: O Married Q Single Q Divorced QSeparatedQWidowed

Age : Soc. Sec: Drivers Lie:

O Part TimePref. Dentist:

EH I would like to receive correspondences via e-mail.Section 3

Referred By:Previous Dentist:

Emergency Contact:Emergency Contact #:

Employer ID:Carrier ID:

Pref. Pharmacy:Pref. Hyg.:

Primary Insurance InformationName of Insured:Insured Soc. Sec:Employer:

Address:Address 2:

City,State , Zip:Rem. Benefits:

Relat ionship to InsuredQ Self Q Spouse Q Child Q OtherInsured Birth Date:

Ins. Company:Address:

Address 2:City,State,Zip:

.00 Rem. Deduct: .00Secondary Insurance InformationName of Insured:Insured Soc. Sec: _Employer:

Addr ess:Address 2:

City, State, Zip:Rem. Benefits:

Insured Birth Date:Relationship toInsuredO Self QSpouse Q Child O Other

Ins. Company:Address:

Address 2:City,State,Zip:

.00 Rem. Deduct: .00


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Edmond Pediatric And Teen Dentistry

MEDICAL HISTORY

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you mayhave, or medication that you may be taking, could have an important interrelationship with the dentistry youwill receive. Thank you for answering thefollowing questions.

Are you under a physician's care now?QYesQNoyouever been hospitalized or had a major operation? O Yes O No

Have you ever had a serious head orneck injury? QYesO NoAre you taking anymedications, pills, or drugs? O Yes O No

Do you ake, or have you taken, Phen-Fen or Redux? O Yes O NoAre you on a special diet? O YesQNo

Do you use tobacco? O YesQNoDo you usecontrolled substances? O YesQNo

If yes, please explain: _If yes, please explain:If yes, please explain:If yes, please explain:

allergic to any of the following?] Aspirin QPenicillin Q] Codeine

Other If yes, please explain:Acrylic Metal Latex Local Anesthetics

rtre yu u - -Pregnant/Trying to getpregnant? O Yes Q No Taking oral contraceptives? O Yes O No Nursing? Q YesQ No

oyou nave, or nave you naa, any or me lonowing f _ __ _O YesQNo

Disease O YesQNoO Yes O NoO YesQ NoO YesQ NoO Yes O No

Heart Valve O YesQ NoJoint O YesQNo

O Yes O NoDisease O YesO NoTransfusion O YesQNo

O Yes O NoEasily O YesQ No

O Yes O NoO Yes O NoO Yes O NoBlisters O YesO No

DisorderQ Yes O NoO Yes O No

Cortisone Medicine O YesQNoDiabetes O Yes O NoDrug Addiction QYes O NoEasily Winded O YesQNoEmphysema O Yes O NoEpilepsy orSeizures O YesQNoExcessive Bleeding O Yes O NoExcessive Thirst O Yes O NoFainting Spelis/DizzinessQ Yes O NoFrequent Cough O Yes O NoFrequent Diarrhea QYes O NoFrequent Headaches O Yes O NoGenital Herpes O Yes O NoGlaucoma O Yes O NoHa y Fever Q Yes O NoHeart Attack/Failure O YesQNoHeart Murmur O Yes O NoHeart Pace Maker Q YesQNoHeart Trouble/Disease O YesQNo

Hemophilia Q Ye s Q NoHepatitis A QYes O NoHepatitis B or C O Yes O NHerpes O Yes O NoHigh Blood Pressure O Yes O NoHives orRash QYes O NoHypoglycemia QYes O NoIrregular Heartbeat QYesQNoKidney Problems QYesO NoLeukemia QYes O NoLiver Disease QYes O NoLow Blood Pressure QYesQNoLung Disease QYesQNoMitral V alve Prolapse O Yes O NoPain inJawJoints O YesQNoParathyroid Disease O Yes O NoPsychiatric Care O Yes O NoRadiation TreatmentsQ Yes O NoRecent Weight Loss QYes O No

Renal Dialysis Q YesQNoRheumatic Fever Q Yes O NoRheumatism Q Yes O NoScarlet Fever Q Yes O NoShingles QYes O NoSickle Cell Disease Q Yes O NoSinus Trouble Q YesQNoSpina Bifida QYesQNoStomach/Intestinal Disease O YesQNoStroke QYes O NoSwelling ofLimbs O Yes O NoThyroid Disease Q YesQNoTonsillitis O YesQ NTuberculosis QYesQNTumors orGrowths (D Yes O NoUlcers O Yes O NVenereal Disease QYes O NYellow Jaundice Q Yes O N

Have youever had anyserious illness not isted above?O Yes O No lf /es, please explain:

Comments:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can bedangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

SIGNATURE OF PATIENT, PARENT, or GUARDIAN DATE


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e d m & r ^ Lpediatric& teendentistry Insurance an d f inancial policyAt E P T D , we believe that eve ry patient dese rves the best care possible. We str ive to take care of every patient'sindividual needs a nd treat them like family. We understand that som e pat ients have insurance and som e do not. W eare here to help any way that we can so here is some impor tant th ings you should know.Initial

1. Your dental benef its are based on a cont ract made betwee n your employer and insurance com pany. If youhave any questions regarding you r dental benef i ts please contact your employer or insurance com panydirectly. Dental ben efit plans will never pay for complet ion of you r dental care. It is only meant to assist you.

2. W e currently accept all private care insurance plans (plans that do not require for you to select a dentistform a list or require our o ff ice to accep t a reduced fee for services.) This means that we wo rk with literally thousandsof companies. Although we can maintain computerized histories of payment by a given company, they do change;therefore it is impo ssible to give you a g uarantee quote at the time of service. We e st imate y our port ion based on themos t up to date information we have, b ut it is ONLY AN ESTIMAT E. I f you w ould l ike to know you r insurance benefit,we will be happy to f ile a "pre-treatmen t authorization" with you r insurance co mp any prior to treatmen t. Keep in mindthis is not a guarantee of cove rage. This does delay treatment but wi l l g ive the exact out of pocket figures you m ayrequire.

3. W e will bill your insurance company as a courtesy. If insurance does not pay within 90 days. EPTD reservesthe r ight to reques t paym ent in full for services from you and let you collect the insurance funds that are due. This israre but is im portant that yo u recognize that the insurance yo u have is a legal contract between you and yourinsurance com pany. O ur off ice is not, and cannot be part of that legal contract. Ultimately, you are responsible for allcharges incurred in our off ice.

4. EPTD doe s require paym ent in full fo r your po rt ion at the time of service. W e acceptW e d o n o t accept checks fo r ove r $500.00 for any patient. I f you are in need of an extended finance opt ions, wealso w ork with ca re credit that will m eet yo u treatme nt plan needs on approve d credit. Please ask if you have an yquest ions about care credit.

5. A specific amount of time is reserved especially for you and we strongly encourage all patients to keep theirappointments. If you must change y our appointment, we require at least a 24hr no tice to avoid a $50/hourcancellation fee.

6. In the event of an em ergen cy after regular business hours a $55 emergency fee will be charged fo restablished pat ients in addition to the necessary treatment fees. Pat ients who are not established in the practicebe charged $125 after hour's em ergency fee.I agree with th e above condit ionsPrint nam e: Date:Patient/Parent Signature: __


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NOTICE OF PRIVACY PRACTICESEdmond Pediatric & Teen DentistryDr Heath Whitfield, D.D.S., MSD3824 S. Boulevard Ste. 110

Edmond, OK 730131:405-513-8811f: 405-513-7083

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BEUSED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THISINFORMATION. PLEASE REVIEW ITCAREFULLY.

We respect our legal obligation to keep health information that identifies you private. We areobligated by law to give you notice of our privacy practices. This Notice describes how we protect yourhealth information and what rights you have regarding it.TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONSTh e most common reason why we use or disclose your health information is for treatment,payment or health care operations. Examples of how we use or disclose information for treatmentpurposes are: setting up an appointment for you; examining your teeth; prescribing medications an dfaxing them to be filled; referring you to another doctor or clinic for other health care or services; or gettingcopies of your health information from another professional that you may have seen before us . Examplesof how we use or disclose your health information for payment purposes are: asking you about yourhealth or dental care plans, or other sources of payment; preparing and sending bills or claims; andcollecting unpaid amounts (either ourselves or through a collection agency or attorney). "Health careoperations" mean those administrative and managerial functions that we have to do in order to run ouroffice. Examples of how we use or disclose your health information for health care operations are:financial or billing audits; internal quality assurance; personnel decisions; participation in managed careplans; defense of legal matters; business planning; and outside storage of our records.

We routinely use your health information inside our office for these purposes without any specialpermission. If we need to disclose your health information outside of our office for these reasons,USES AND DISCLOSURES FOR OTHER REASONSWITHOUT PERMISSIONIn some limited situations, the law allows or requires us to use or disclose your health informationwithout your permission. Not all of these situations will apply to us; some may never come up at our officeat all. Such uses or disclosures are: when a state or federal law mandates that certain health information be reported for a specificpurpose; for public health purposes, such as contagious disease reporting, investigation or surveillance;and notices to and from the federal Food and Drug Administration regarding drugs or medicaldevices; disclosures to governmental authorities about victims ofsuspected abuse, neglect or domesticviolence; uses anddisclosures for health oversight activities, such as for the licensing of doctors; for auditsby Medicare or Medicaid; or for investigation of possible violations of health care laws;

disclosures for judicial and administrative proceedings, such as in response to subpoenas ororders of courts or administrative agencies; disclosures for law enforcement purposes, such as to provide information about someone who isor is suspected to be a victim of a crime; to provide information about a crime at our office; or toreport a crime that happened somewhere else; disclosure to a medical examiner to identify a dead person or to determine the cause of death; or


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ask us to amendyour health information if you think that it is incorrect or incomplete. If we agree,we will amend the information within 60 days from when you ask us. We will send the corrected 'information to persons who we know got the wrong information, an d others that you specify. If wedo not agree, you canwrite a statement of your position, and we will include itwith your healthinformation along with an y rebuttal statement that we may write. Once your statement of positionand/or our rebuttal is included in your health information, we will send it along whenever we makea permitted disclosure of your health information. By law, we can have one 30 day extension oftime to consider a request for amendment if we notify you in writing of the extension. If you wantto ask us to amend your health information, send a written request, including your reasons for theamendment, to the office contact person at the address, fax or E mail shown at the beginning ofthis Notice. get a list of the disclosures that we have made of your health information within the past six years(or a shorter period if you want). By law, the list will no t include: disclosures for purposes oftreatment, payment or health care operations; disclosures with your authorization; incidentaldisclosures; disclosures required by law; and some other limited disclosures. You are entitled toon e such list pe r year without charge. If you want more frequent lists, you will have to pay forthem in advance. We will usually respond to your request within 60 days of receiving it, but by lawwe can have one 30 day extension of time if we notify you of the extension inwriting. If you wanta list, send a written request to the office contact person at the address, fax or E mail shown atthe beginning of this Notice. get additional paper copies of this Notice of Privacy Practices upon request. Itdoes not matter

whether you got one electronically or in paper form already. If you want additional paper copies,send a written request to the office contact person at the address, fax or E mail shown at thebeginning of this Notice.OUR NOTICE OF PRIVACY PRACTICESBy law, we must abide by the terms of this Notice of Privacy Practices until we choose to changeit. We reserve the right to change this notice at any time as allowed by law. If we change this Notice, thenew privacy practices will apply to your health information that we already have as well as to suchinformation that we may generate in the future. If we change our Notice of Privacy Practices, we will postthe new notice in our office, have copies available in our office, and post it on our Web site.COMPLAINTSIf you think that we have no t properly respected the privacy of your health information, you arefree to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. Wewill no t retaliate against you if you make a complaint. If you want to complain to us, send a writtencomplaint to the office contact person at the address, fax or E mail shown at the beginning of this Notice.If you prefer, you can discuss your complaint in person or by phone.FORMORE INFORMATIONIf you want more information about our privacy practices, call or visit the office contact person atthe address or phone number shown at the beginning of this Notice.

tear hereACKNOWLEDGEMENT OF RECEIPT

I acknowledge that I received a copy of the Notice of Privacy Practices.Patient name .Signature . Date

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