ID:

First Name:

Chart lD:

Patient ls: ;- Policy Holder

i-r Responsible Party

;-Responslble Pafi (if someone otherthan the patient)------

I First Name:

Address:

City, State, Zip:

PATIENT REGISTRATION

Last Name: Middle lnitial:

Prehred Name:

EmploymentStatus: Q Futt Time Q eartnme O Retired

student status: Q rutttime Q pa* time

Middle lnitial:

Address 2:

Pager; ^-.-'-.-.-

Ext Cellular:

Address 2:

Drivers Lic:

Relationship to lnsured:Q Sef O Spouse C Chitd O Ottrer

lnsured Birth Date:

lns. Company;

Address:

Address 2:

City,State,Zip:

LastName:

Home Phone:

Birth Date:

Work Phone:

Soc Sec: Drivers Lic:

I

--9rygg:lglfg'.:*"{1'"vi!s"i!'3ti".!-9fryg ryg'* Pol9F"ld"'- o secondarv r"ry_irPatient lnformation

Address:

City: State / Zip: Pager:

Home Phone: Woft Phone:

Sex: Quate QFemate Maritalstatus: Ouanleo QSingte QDivorced Q$eparatedQWooweoBirth Date: Age: __._ Soc. Sec:

E-mail: ] lwoutO like to roceive conespondences via e-mail.

Section 2 Section 3

Pref. Dentist:

CC # ON FILE: :

CC CARDTYPE::

CC SECURITY CODE::

CC EXPIRATION DATE::

Pref. Pharmacy:

Pref. Hyg.:

r- Primary lnsurance lnfomation

Medicaid lD:

Employer lD:

i Carrier lD:

Name of lnsured;

r lnsured Soc. Sec;

Employer: ___.

Address: .r

Address 2:

City,State,Zip:

Rem. Benefits: .00 Rem. Deduci: .00

-Secondary lnsurance lnformation -

Name of lnsured:

lnsured Soc. Sec: lnsured Birth Date:

Relationship to lnsured:Q SeF Q Spouse Q Cniu Q Ottrer

lns. Company:

Address:

Address 2:

City,State,Zip;

, Employer:

II Address:

i Address 2:

r City,State,Zip:

i Rem. Benefits: ,9Q Rem. Dedud: .00

Center For Dentistry

II'IEDICAL HISTORY

PATIENT NAME Birth Date

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 interrelalionship with the dentbtry you will receive. Thank you for answering thefollowing questions.

Are you under a physician's care now? O Ves O HoHave you ever been hospitalized or had a major operation?O Yes (_r\ No

Have you ever had a serious head or neck injury? O Ves O ruo

Are you taking any medications, pills, or drugs? O Ves fj HoDo you take, or havo you taken, Phen-Fen or Redux? O Ves O ttoHave you ever taken Fosamax, Boniva, Aclonel or any , , ., /\ . .-other

medications containing bisphosphonat$i i u Yes \ j No

Are you on a special diet? O Yes O No

Do you use tobacco? O Ves O ruo

Do you use controlled substances? C) Ves O ttoWomen: Are youPregnanUTrying to get pregnant? O Yes (_r\ No Taking oral contraceptivesZ O Yes O No

Are you allergic to any of the following?

Aspirin Penicillin Codeine LocalAnesthetics Acrylic

Other lf yes, please explain:

lf yes, please explain:

lf yes, please explain:

lf yes, please explain:

lf yes, please explain:

Nursing? Q

Metal

ves O ruo

Latex Sulfa drugs

Do you have, or have you had, any ofthe following?AIDS/HlVPositive a) Ves O No

Alzheimer's Disease O Ves O ttoCortisoneMedicine O Yes [) ruo Hemophilia

HepatitisAOYesONoO Yes C) tlo

Hepalitis I or c () ves O ttoHerpes O ves [) No

High Blood Pressure (-) Yes l) xoHigh Cholesterol Q ves Q No

HivesorRash () ves Q No

Hypoglycemia OVesQttolnegularHeartbeat Oves Q ttoKidney Problems O Ves C) Ho

Radiation Treatments [) yes C) UoRecentweightloss O yes () Uo

Anaphylaxis O ves O tloAnemia :-) ves O No

Angina () Yes O ruo

Arthritis/cout j ves'j tto

' Artificial Heart Valve O Ves O tloArtificial JointAsthmaBlood Disease

Blood Transfusion

Breathing Problem

Bruise Easily

Cancer

Chemotherapy

Chest Pains

() Yes O tto

lj ves O t{o

O ves l-) No

C) ves O No

OYesOruoi-; ves Q tto

O ves (_; Ho

!veslHoi) ves O No

Diabetes

DrugAddiction

Genital Herpes

Glaucoma

Hay Fever

Heart MurmurHeart Pac€maker

Q ves O tto

OvesIruo

l) Yes ij Ho

OvesOHoi-l Yes O tto

() ves Q Ho

{) ves O Ho

Leukemia

Liver DigeageO ves - tto

OvesOruo

Renal Dialysis

Rheumatic Fever

Rheumatism

Scarlet Fever

Shingles

Sickle Cell Disease

Sinus Trouble

Spina Bifida

Stroke

Swelling of LimbsThyroid Diseas€TonsillitisTuberculosisTumors or GrowthsUlcersVenereal DiseaseYello,t, Jaundice

{) Yes (,r Ho

J ves [) ruo

OvesOHoQ ves Q tto

Q ves J tto

O Yes (.1 Po

O ves l) Ho

OvesOruo

OvesQruoOvesOruoOyesONo,OvesOttor() ves /-) Ho '

O ves () ruo

O ves O ttoOvesOruo() ves O tlo r

Easily Winded O Yes O ruo

Emphysema OYesOttoEpilepsyorseizures O Yes (; Ho

Excessive Bleeding O Yes O NoExcessive Thirst r.) Yes O NoFaintingspells/DizzinessQ Ves O No

Freguent Cough OvesOruoFrequentDiarrhea Oves O No

Frequent Headaches O Yes C) ruo

Stomach/lnlestinal Disease () ves tC ruo

HeartAttacldFailure O Yes [) lto

Low Blood Pressure () ves () ttoLung Disease OvesONoMilral Valve Prolapse O yes O tloosteoporosis OvesOHoPain in Jaw Joints O ves O Ho

Parathyroid Disease [) Yes Q No

Psychiatric Care O ves O Ho

cold Sores/Fever Blisters O ves O ttoCongenital HeartDisorderl-; Yes l) No

Convulsions L) Yes O no HeartTrouble/Disease Oves O tto

Have you ever had any serious illness not listed above?O ves O tto

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. lt is my responsibility to inform the d€ntal office of any changes in medical status.

SIGNATURE OF PATIENT, PARENT, oT GUARDIAN DATE

We request payment in full for all patients without insurance or those pdtients that

obtain Center for Dentistry lnsurance. ._-For those patients with dental insurance, we request payment in full for your deductible

and estimated co-payment at the time of service. Your insurance is an agreement

between you and your insurance company. You are ultimately responsible for your

treatment fees.

A 50% retainer fee is required for all laboratory procedures.

We accept all major credit cards, personal checks, cash, chase financing or care credit.

I agree to pay for any appointments failed or cancelled without a 24 hour notice in the

amountof$75.00firstoccurrence'$150.00secondoccurrence.-

I understand I am obligated and responsible to pay for my treatment. ln the event this

account becomes delinquent by 60days, Center for Dentistry retains the right to collect

ltola annual interest, attorney fees and court costs incurred in an attempt to collect this

account.

Date

Patient Signature (Parent or Guardian for Minor)

Dear Valued Patient,

Our purpose is to help our patients keep their teeth and gwns healthy for life. Properscheduling of appointments is vital to that endeavor. Therefore, we ask for yourcooperation regarding the following appointnent policy:

l. Every effort is made to keep on schedule so we respectfirlly ask patients to beprompt and keep their appointments. We try to remind paiients Ly telephone priorto their appoinhnent but please do not depend on this courtesy. If we are unableto reach you, your appointnent card will serve as the confirrnation of yourappointment and implies yotu obligation to be present. That time has beenreserved especially for you. This means no other patient has been scheduled forthat particular time slot, and that anyone else wishiqg to schedule for that time hashad to be given a different time forttreir appointnnent. We reserve the right tocharge for office visits cancelled or broken without 2 business days advancenotice (e.g. if your appointment is scheduled for Monday at 3 P.M., and your needto re-schedule, you must call us before the prior Thursday at 3 P.M.). Exceptionsto this policy can be determined only on an individual basis according to thecircumstances. The broken appointrrent charge will depend on the procedure andtime reserved. These charges are allowed by your insurance company butconsidered as the patient's responsibility to pay.

2, In order to ensure that we keep to our schedule, and yours, as much as possibleand to minimize patient waiting time, it is necessary to schedule certainprocedures for specific times during the day. This allows us to provide you withthe excellence in care that you expect arrd deierve. We know that your time isvaluable and that none of our patients want to spend any longer in fhe dentist'sclinic than they have to. Scheduling specified procedures for specific time slotsallows us to be more efiEcient with your treatnent and actually minimizes thetime you have to spend at our office.

If you have any questions about the policn do not hesitate to ask our office staff Webelieve that good communication is the key to excellence in dental care.

THE ANTI-SEXUAL HARASSMENT POLICY OF THIS

OFFICE:

This office has an anti-sexual harassment policy in place.

Anyone violating this policy will be asked to discontinue

such behavior.

lf the perpetrator is an employee and he or she should

continue such behavior, his or her employment will be

terminated,

ln case the perpetrator is a patient and he or she should

continue such behavior, the patient-doctor relationship will

be terminated according to the office's patient dismissal

procedure.

NOTE:

Please be aware that the above patient information will not prevent a lawsuit on thatbass. lt will, however, increase the likelihood of prevaiting.

Send to the patient with his/her welcome package or provide as brochure in the waitingroom.

CONDITIONS, LIMITATIONS AND COVERAGE

1. Hereafter, Center for Dentistry Plan will be called the "P|-AN".2. The PLAN is administered by Center for Dentistry.3. Membership fee for the PLAN is an annualfee. The membership fee is non-

refundable.4. The PLAN will go into effect when the membership fee is met.5. The P[-AN fees for services are limited to Center for Dentistry only.6. There is a $15 office co pay at every dental visit for infection control.7. Broken appointments without 24 hour notification are subject to a failed

appointment fee of a minimum $55.00.8. Co-payment for services rendered is due at time of service. No exceptions.L Additional services will not be rendered if at any time you have a balance on your

account.10. The term "child" is anyone under the age of 18 years of age.11.The term "adulf is anyone 18 years of age and older.12.The plan provides 2 dental and/or periodontalexaminations, 2 routine cleanings

(prophylaxis) or 2 periodontal maintenance cleanings, two fluoride treatments, 2oral cancer/soft tissue examinations, laser cavity detection evaluation, and 1 setof 24 bitewing x-rays and 2 anterior periapical x-rays per membership year.

13.All other restorative services will have a20o/o adjustment off the usual andcustomary fees.

14. Not valid with traditional dental insurance.

Membership Fee Schedule:

1. First Adult .......$190.00

Second Adult. ....$140.00

Adults Thereafter OnSame Account. . ... ... ..$140.00

chird. ......$95

Each Child Thereafter OnSame Account. ....$95

Center Far Dentistry931 West 75n Street, Suite 107

Naperville, IL. 60565

OFFICE RULES REGARDING MINORS (parent may leave)

We, at Center For Dentistry provide a caring environment and the best treatment

to all our patients, young and not so young. Our patients are very dear to us and we want

to create a comfortable environment and build a trusting bond betvreen your children and

our staff. We pride ourselves on our patient care and concem - this includes assisting

your child in establishing his or her independent relationship with our staff. At the same

time, questions or concerns might arise which demand the input of the parent or guardian.

In order to accomplish the above goals, we ask you to heed the following:

1. Please do not accompany your child into the operatory, unless requested to do so by

the doctor or the staff,

2. Please do not leave the waiting room area, if your child is under the age of 12.

3. If your child is 12 or older and you must leave the office while your

child is being treated,

a. Please get permission from the doctor to leave the child in ow care -depending on the procedure, we might want you to stay;

b. If you get the green light from us to leave, please leave your cellular

phone number or other phone number where you can be reached, with the

front desk.

4. Please return at the time specified by the front desk to accompany your child home.

Thank you for your cooperation.

Center For Dentistry931 West 75ft Street, Suite l0?

Naperville, IL. 60565

OFFICE RULES REGARDING MINORS (parent to stay)

We, at Center For Dentistry provide a caring environment and the best treatrnent

to all our patients, young and not so young. Our patients zre very dear to us and we want

to create a comfortable and trusting relationship between your children and our staff.

You as t}e parent are avital link to making the visit to our office a pleasant experience

for your children. In order to care for your children the proper way, we ask you, the

parent or legal guardian, to bring your child to the office and remain in the waiting room

until the end of your child's appointment. We provide a comfortable waiting area, with

magazines, newspapers and coffee and appreciate you taking the time to wait for your

children.

At this young age, your child will feel more at ease knowing you are "right

around the corner", while establishing some independence in interacting with the doctor

and the staff "on his or her own." This way your child can focus on what is required of

him or her without the stress of knowing that the parent is gone.

For our office, your presence is beneficial as well. Should there be concern or

questions, which demand your attention or input, we can discuss the scenario with you

immediately. Should the treatment plan have to be modified, you are there to help make

the decision. Should the appointment be finished earlier than expected, you are there to

take your child home or back to school.

We appreciate you helping us in caring for your child and taking the time to

ensure your child's oral health in the best environment there is: yours.

NOTICE OF PRIVACY PRACTICES

Carl E. Henley, DDS. & Associates PC.931 West 75th. Street, Suite #107

Phone(630)357-9393Fax(630)357-9380

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

We respect our legalobligation 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 OPERATIONSThe 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 treatment

i:uiposes are: setting up an appointment for you; examining your teeth; prescribing medications and

iaxing them to be filled; referring you to another doctor or clinic for other health care or services; or getting

copies 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 your

health or dental care plans, or other sources of payment; preparing and sending bills or claims; and

collecting 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 ouroifice. Examples of how we use or disclose your health information for health care operations are:

financial or bitling 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, lf we n6ed to disclose your health information outside of our office for these reasons, we

usually will not ask you for specialwritten permission.

USES AND DISCLOSURES FOR OTHER REASONS WTHOUT PERMISSIONln some limited situations, the law allows or requires us to use or 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,r for public health purposes, such as contagious disease reporting, investigation or surveillance;

and' notices to and fiom the federal Food and Drug Administration regarding drugs or medicaldevices;

. disclosures to governmental authorities about victims of suspected abuse, neglect or domesticviolence;

. uses and disclosures 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;

r 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; orto funeral directors to aid 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 thepresident or high ranking government officials; for lawful national intelligence activities; for militarypurposes; or for the evaluation and health of members of the foreign service;

o disclosures of de-identified information;o disclosures relating to worker's compensation programs;r disclosures of a "limited data sef' for research, public health, or health care operations;r incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;o disclosures to "business associates" who perform health care operations for us and who commit

to respect the privacy of your health information;

Unless you object, we will also share relevant information about your care with your family orfriends who are helping you with your dental care.

APPOINTMENT REMINDERSWe may call or write to remind you of scheduled appointments, or that it is time to make a routine

appointment. We may also call or write to notiff you of other treatments or services available at our officethat might help you. Unless you tellus othenryise, we will mailyou an appointment reminder on a postcard, and/or leave you a reminder message on your home answering machine or with someone whoanswers your phone if you are not home.

OTHER USES AND DISCLOSURESWe will not make any other uses or disclosures of your health information unless you sign a

written "authorization form." The content of an "authorization form" is determined by federal law.Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes,you may initiate the process if it's your idea for us to send your information to someone else. Typically, inthis situation you will give us a properly completed authorization form, or you can use one of ours.lf we initiate the process and ask you to sign an authorization form, you do not have to sign it. lf you donot sign the authorization, we cannot make the use or disclosure. lf you do sign one, you may revoke it atany time unless we have already acted in reliance upon it. Revocations must be in writing. Send them tothe office contact person named at the beginning of this Notice.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATIONThe law gives you many rights regarding your health information. You can:

r ask us to restrict our uses and disclosures for purposes of treatment (except emergencytreatment), payment or health care operations. We do not have to agree to do this, but if weagree, we must honor the restrictions that you want. To ask for a restriction, send a writtenrequest to the office contact person at the address, fax or E Mail shown at the beginning of thisNotice.

o ask us to communicate with you in a confidentialway, such as by phoning you at work rather thanat home, by mailing health information to a different address, or by using E mail to your personalE Mail address, We will accommodate these requests if they are reasonable, and if you pay usfor any extra cost. lf you want to ask for confidential communications, send a written request tothe office contact person at the address, fax or E mail shown at the beginning of this Notice.

o ask to see or to get photocopies of your health information. By law, there are a few limitedsituations in which we can refuse to permit access or copying. For the most part, however, youwill be able to review or have a copy of your health information within 30 days of asking us (orsixty days if the information is stored off-site). You may have to pay for photocopies in advance.lf we deny your request, we will send you a written explanation, and instructions about how to getan impartial review of our denial if one is legally available. By law, we can have one 30 dayextension of the tirne for us to give you access or photocopies if we send you a written notice ofthe extension. lf you want to review or get photocopies of your health information, send a writtenrequest to the office contact person at the address, fax or E mail shown at the beginning of thisNotice.

. ask us to amend your health information if you think that it is incorrect or incomplete. lf we agree,we will amend the information within 60 days from when you ask us. We willsend the correctedinformation to persons who we know got the wrong information, and others that you specifi7. lf wedo not agree, you can write a statement of your position, and we will include it with your healthinformation along with any rebuttal statement that we may write. Once your statement 0f 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. lf you wantto ask us to amend your health information, send a written request, including your reasons for theamendrnent, to the office contact person at the address, fax or E mail shown at the beginning ofthis Notice.

r g€t a list of the disclosures that we have made of your health information within the past six years(br a shorter period if you want). By law, the list will not 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 toone such list per year without charge. lf 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 in writing. lf 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.

o get additional paper copies of this Notice of Privacy Practices upon request. lt does not matterwhether you got one electronically or in paper form already. lf you want ldditional 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 untilwe choose to change

it. We reserveihe right to chang-e this notice at any time as allowed by law, lf we change this Notice, thenew privacy practices will apply to your health information that we alreadyiave as well as to suchinformationthat we may generate in the future. lf we change our Notice of Privacy Practices, we will post

the new notice in our office, have copies available in our office, and post it on our Web site'

COMPLAINTSlf you think that we have not properly respected the privacy of your he{!! information, you ar9

free to corilplain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. Wewill not retaiiate against you if you make a complaint. lf you want to complain to us, send a written

complaint to the okce c6ntact-person at the address, fax or E mail shown at the beginning of this Notice.

lf you prefer, you can discuss your complaint in person or by phone'

FOR MORE INFORMATIONlf you want more information about our privacy practices, call or visit the office contact person at

the address or phone number shown at the beginning of this Notice.

tear here

ACKNOWLEDGEMENT OF RECEIPT

I acknowledge that I received a copy of Carl E. Henley, D.D.S, Notice of Privacy Practices.

Patient name

Signature Date

CARL E. HENLEY, D.D.S.931 West 75th Street Suite #107

Ph(630)357-9393Fax(630)357-9830

AUTHORIZATION FOR RELEASE OF IDENTIFYTNG HEALTH INFORMATION

I authorizelhe profession-alofiice of my dentist named above to release health information identifying me[including if applicable, information about HIV infection or AIDS, information about substance abuie -treatment, and information about mental health servicesl under the following terms and conditions:

1. Detailed description of the information to be released:

2. To whom may the information be released [name(s) or class(es) of recipients]:

3. The purpose(s) for the release (if the authorization is initiated by the individual, it is permissibte tostate "at the request of the individual" as the purpose, if desired by ihe individual):

4. Expiration date or event relating to the individual or purpose for the release:

It is completely your decision whether or not to sign this authorization form. We cannot refuse to treat youif you choose not to sign this authorization.

lf you sign this authorization, you can revoke it later. The only exception to your right to revoke is if wehave already acted in reliance upon the authorization. lf you want to revoke your authorization, send us awritten or electronic note telling us that your authorization is revoked. Send this note to the office contactperson listed at the top of this form.

When your health information is disclosed as provided in this authorization, the recipient often has no legalduty to protect its confidentiality. ln many cases, the recipient may re-disclose the information as he/shdwishes. Sometimes, state or federallaw changes this possibility.

[For marketing authorizations, include, as applicable: We willreceive direct or indirect remuneration froma third party for disclosing your identifiable health information in accordance with this authorization.J

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. I AUTHORIZE THEDISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBED IN THIS FORM.

Patient name

Patient number

Patient address

Patient phone number

Patient signature

lf you are sig-ning as a personal representative of the patient, describe your relationship to the patient andthe source of your authority to sign this form:

Relationship to Patient

Source of Authority,

Print Name

This letter serves as an explanation to our patients what the HIPAA Privacy Policy isall about.

PRIVACY STANDARDS UNDER HIPAAThe Health Insurance Portability and Accountability Act:

Dear Patient:

The Government has enacted the Health Insurance Porrability and Accountability Act and

with it several privacy standards and rights which affect you, our patient, and your

healthcare information which you entrusted to us. Under para.42 U.S.C. para.164.512,you have a right to receive a written notice of our inforrnation practices.

Onr office may use protected health information with your individualized authorization,42 TJ .5.C., pan. 164.506 (aX l Xii); para 164.508, or for purposes of treatment, payment,

and healthcare operatiotls. Para. 164.506(aXlXi). As part of our office healthcare

operations, we reserve the right to leave appointment reminder messages on your home

answering machine. We may use or disclose such information without patient

authorization for specific public policy pu{poses, including public health, research, health

oversight, law enforcement. and use by coroners. Paru. 164.510(b)' Further, we may

discloie protected information when required to do so by other laws, such as mandatory

reporting requirements. Para. 164.5 10(n).

We limit the uses and disclosures of your health care information to those specified

above. We reserve the right to revise the uses and disclosures as necessary .

The following rights apply to our patients:

. You have the right to inspect and copy your records (we charge a reasonable fee

for reproduction of "vour

records) (42 U.S.C. para' 164'514). You haue u rigirt to an accounting of disclosures other than for treatment,

payment, and healthcare operations (para. 164.515). You have the right to request that we protect health information, except

emergency treatment information, from further Llse or disclosure for treatment,

payment, or healthcare operations. We are not obligated to grant the request.

(para. 16a.506(cXl). *ou have the right to request amendments or conections of inaccurate or

incomplete protected health information (parc' 164'516). You have the right to opt out of some of our office policies as indicated in our

Privacy Notice and on our Acknowledgement form

We hope that these explauations will reassure you thatprivacy standards enacted by the legislature.

Should you have any questions and concerns regarding

implementation, please contact

Sincerely,

Your Dental Office

we ale in compliance with the

the privacy regulations and oruat ouf office.

Please take a few moments to fill out this brief survey. Your answers will enable us toserve you better!

l. What specific services do you look for or consider important when going to thedentist? (check all that apply)

A. CleaningB. Cosmetic (bleaching, straightening, etc.)C. Restorative (fillings, crowns, bridges, etc.)D. Personal serviceE. Other (please explain): ........,.

2. Is there any dental service you need or want that we do not provide? If so, whichones?

3. What do you like the least aboutvisiting the dentist? (check all that apply)

A. InjectionsB. DiscomfortC. Not understanding the procedures or treatment being done

D. Drilling (what about it, for example: the noise, the vibration, etc.)E. Other (please explain)

4. What do you like the most about coming to our dental clinic, or what do you feelwe do the best?

5. In what areas can we improveo to make your experience in our dental clinicbetter? (please be specific as possible)

THANK YOU VERY MUCH FOR YOURANSWERS.