Patient Sign-in

Patient Registration Form

Patient Sign-in
New patient Registration
Medical History
Medical history
Dental History
Dental history

Patient Registration( * mandatory to fill )

Is the Patient Under 18(Minor)?
Yes
No

Guardian Information

How do we contact you?( * mandatory to fill )

Who do we contact in case of an emergency?( * mandatory to fill )

Medical History

What is your estimate of your general health?
Excellent
Good
Fair
Poor

(All questions are required * )

Do you have or have you ever had:

Hospitalization for illness or injury
Yes
No
An allergic or bad reaction to any of the following:
Heart problems, or cardiac stent within the last six months
Yes
No
History of infective endocarditis
Yes
No
Articial heart valve, repaired heart defect (PFO)
Yes
No
Pacemaker or implantable debrillator
Yes
No
Orthopedic implant (joint replacement)
Yes
No
Rheumatic or scarlet fever
Yes
No
High or low blood pressure
Yes
No
I have answered all the above questions

Medical History

A stroke (taking blood thinners)
Yes
No
Anemia or other blood disorder
Yes
No
Prolonged bleeding due to a slight cut (INR > 3.5)
Yes
No
Pneumonia, emphysema, shortness of breath, sarcoidosis
Yes
No
Tuberculosis, measles, chicken pox
Yes
No
Asthma
Yes
No
Breathing or sleep problems (i.e. sleep apnea, snoring, sinus)
Yes
No
Kidney disease
Yes
No
Liver disease
Yes
No
Jaundice
Yes
No
Thyroid, parathyroid disease, or calcium deciency
Yes
No
Hormone deficiency
Yes
No
High cholesterol or taking statin drugs
Yes
No
Diabetes (HbA1c =
Yes
No
Stomach or duodenal ulcer
Yes
No
Digestive or eating disorders (e.g., celiac disease, gastric reux, bulimia, anorexia)
Yes
No
Osteoporosis/osteopenia (i.e. taking bisphosphonates)
Yes
No
Arthritis
Yes
No
Autoimmune disease (i.e. rheumatoid arthritis, lupus, scleroderma)
Yes
No
Glaucoma
Yes
No
Contact lenses
Yes
No
Head or neck injuries
Yes
No
Epilepsy, convulsions (seizures)
Yes
No
Neurologic disorders (ADD/ADHD, prion disease)
Yes
No
Viral infections and cold sores
Yes
No
Any lumps or swelling in the mouth
Yes
No
Hives, skin rash, hay fever
Yes
No
STI/STD/HPV
Yes
No
Hepatitis (type)
Yes
No
HIV/AIDS
Yes
No
Tumor, abnormal growth
Yes
No
Radiation therapy
Yes
No
Chemotherapy, immunosuppressive medication
Yes
No
Emotional difficulties
Yes
No
Psychiatric treatment
Yes
No
Antidepressant medication
Yes
No
Alcohol/recreational drug use
Yes
No
I have answered all the above questions

Medical History

Are You:

Presently being treated for any other illness
Yes
No
Aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)
Yes
No
Taking medication for weight management
Yes
No
Taking dietary supplements
Yes
No
Often exhausted or fatigued
Yes
No
Experiencing frequent headaches
Yes
No
A smoker, smoked previously or use smokeless tobacco
Yes
No
Considered a touchy/sensitive person
Yes
No
Often unhappy or depressed
Yes
No
Taking birth control pills
Yes
No
Currently pregnant
Yes
No
Diagnosed with a prostate disorder
Yes
No

List all medications, suppliments, and or vitamins taken within the last two years.

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Referred by*
How would you rate the condition of your mouth?
Excellent
Good
Fair
Poor
I routinely see my dentist every:
3 mo.
4 mo.
6 mo.
12 mo.
Not Routinely

PLEASE ANSWER YES OR NO TO THE FOLLOWING:

Personal History

Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most)?
Yes
No
Have you had an unfavorable dental experience?
Yes
No
Have you ever had complications from past dental treatment?
Yes
No
Have you ever had trouble getting numb or had any reactions to local anesthetic?
Yes
No
Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?
Yes
No
Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?
Yes
No

Gum and Bone

Do your gums bleed or are they painful when brushing or flossing?
Yes
No
Have you ever been treated for gum disease or been told you have lost bone around your teeth?
Yes
No
Have you ever noticed an unpleasant taste or odor in your mouth?
Yes
No
Is there anyone with a history of periodontal disease in your family?
Yes
No
Have you ever experienced gum recession?
Yes
No
Have you ever had any teeth become loose on their own (without an injury), or do you have diculty eating an apple?
Yes
No
Have you experienced a burning or painful sensation in your mouth not related to your teeth?
Yes
No

Tooth Structure

Have you had any cavities within the past 3 years?
Yes
No
Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
Yes
No
Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
Yes
No
Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?
Yes
No
Do you have grooves or notches on your teeth near the gum line?
Yes
No
Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
Yes
No
Do you frequently get food caught between any teeth?
Yes
No

Bite and Jaw Joint

Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
Yes
No
Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?
Yes
No
Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?
Yes
No
In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?
Yes
No
Are your teeth becoming more crooked, crowded, or overlapped?
Yes
No
Are your teeth developing spaces or becoming more loose?
Yes
No
Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?
Yes
No
Do you place your tongue between your teeth or close your teeth against your tongue?
Yes
No
Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
Yes
No
Do you clench or grind your teeth together in the daytime or make them sore?
Yes
No
Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?
Yes
No
Do you wear or have you ever worn a bite appliance?
Yes
No

Smile Characteristics

Is there anything about the appearance of your teeth that you would like to change (shape, color, size)?
Yes
No
Have you ever whitened (bleached) your teeth?
Yes
No
Have you felt uncomfortable or self conscious about the appearance of your teeth?
Yes
No
Have you been disappointed with the appearance of previous dental work?
Yes
No
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

PATIENT HIPAA CONSENT FORM

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

  • Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
  • Obtaining payment from third party payers (e.g. my insurance company);
  • The day-to-day healthcare operations of your practice.

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use of disclosure that occurred prior to the date I revoke this consent is not affected.

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

HIPAA Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW DENTAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your dentist, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the dentist's practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a dentist to whom you have been referred to ensure that the dentist has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your dentist's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your dentist. We may also call you by name in the waiting room when your dentist is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, and Organ Donation, Research, Criminal Activity, Military Activity and National Security, Workers' Compensation, Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to object unless required by law.

You may revoke this authorization at any time, in writing, except to the extent that your dentist or the dentist's practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights
Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your dentist is not required to agree to a restriction that you may request. If dentist believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

You may have the right to have your dentist amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

This notice was published and becomes effective on/or before April 14, 2003.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )
Thank you for visiting Willow Dental. We want your visit to be pleasant and comfortable. Please help us by completing this form
Patient Information

Personal Details

Title:     First Name:     Last Name:    
Date Of Birth:     Social Security Number:    
Gender:     Marital Status:    
Is the Patient Under 18( Miner )? Yes No

Guardian Details

First Name:     Last Name:     Date Of Birth:    
Phone Number:     Relation to Patient:    

Address

Street Address:     City:     State:     Zip:    
Home Phone:     Cell Phone:     Work Phone:    
Email Address:     Driver's License:    

Emergency Contact Information

Name:     Relation:     Home Phone:     Work Phone:    
Address:     City:     State:     Zip Code:    

Professional Information

Employer Name:     Position:    
Employer Address:     City:     State:     Zip Code:    
Medical History
Name of Physician/and their specialty:    
Most recent physical examination:    
Purpose:    
What is your estimate of your general health?
Excellent
Good
Fair
Poor

Do you have or have you ever had:

Hospitalization for illness or injury
Yes
No
An allergic or bad reaction to any of the following:
Aspirin
Ibuprofen
Acetaminophen
Codeine
Penicillin
Erythromycin
Tetracycline
Sulfa drugs
Local anesthetics
Fluoride
Metals(nickel, gold, silver) If Metals:
Latex
Nuts If nuts:
Fruit If fruit:
Other If other:
Heart problems, or cardiac stent within the last six months
Yes
No
History of infective endocarditis
Yes
No
Articial heart valve, repaired heart defect (PFO)
Yes
No
Pacemaker or implantable debrillator
Yes
No
Orthopedic implant (joint replacement)
Yes
No
Rheumatic or scarlet fever
Yes
No
High or low blood pressure
Yes
No
A stroke (taking blood thinners)
Yes
No
Anemia or other blood disorder
Yes
No
Prolonged bleeding due to a slight cut (INR > 3.5)
Yes
No
Pneumonia, emphysema, shortness of breath, sarcoidosis
Yes
No
Tuberculosis, measles, chicken pox
Yes
No
Asthma
Yes
No
Breathing or sleep problems (i.e. sleep apnea, snoring, sinus)
Yes
No
Kidney disease
Yes
No
Liver disease
Yes
No
Jaundice
Yes
No
Thyroid, parathyroid disease, or calcium deciency
Yes
No
Hormone deficiency
Yes
No
High cholesterol or taking statin drugs
Yes
No
Diabetes (HbA1c =
Yes
No
If yes:
Stomach or duodenal ulcer
Yes
No
Digestive or eating disorders (e.g., celiac disease, gastric reux, bulimia, anorexia)
Yes
No
Osteoporosis/osteopenia (i.e. taking bisphosphonates)
Yes
No
Arthritis
Yes
No
Autoimmune disease (i.e. rheumatoid arthritis, lupus, scleroderma
Yes
No
Glaucoma
Yes
No
Contact lenses
Yes
No
Head or neck injuries
Yes
No
Epilepsy, convulsions (seizures)
Yes
No
Neurologic disorders (ADD/ADHD, prion disease)
Yes
No
Viral infections and cold sores
Yes
No
Any lumps or swelling in the mouth
Yes
No
Hives, skin rash, hay fever
Yes
No
STI/STD/HPV
Yes
No
Hepatitis (type)
Yes
No
HIV/AIDS
Yes
No
Tumor, abnormal growth
Yes
No
Radiation therapy
Yes
No
Chemotherapy, immunosuppressive medication
Yes
No
Emotional difficulties
Yes
No
Psychiatric treatment
Yes
No
Antidepressant medication
Yes
No
Alcohol/recreational drug use
Yes
No

Are You:

Presently being treated for any other illness
Yes
No
Aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)
Yes
No
Taking medication for weight management
Yes
No
Taking dietary supplements
Yes
No
Often exhausted or fatigued
Yes
No
Experiencing frequent headaches
Yes
No
A smoker, smoked previously or use smokeless tobacco
Yes
No
Considered a touchy/sensitive person
Yes
No
Often unhappy or depressed
Yes
No
Taking birth control pills
Yes
No
Currently pregnant
Yes
No
Diagnosed with a prostate disorder
Yes
No
Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. List all medications, suppliments, and or vitamins taken within the last two years. (i.e. Botox, Collagen Injections)    

List all medications, suppliments, and or vitamins taken within the last two years.

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
Dental History
Referred by:    
How would you rate the condition of your mouth?
Excellent
Good
Fair
Poor
Previous Dentist:     How long have you been a patient? (Months/Years):    
Date of most recent dental exam (Months/Years):     Date of most recent x-rays:    
Date of most recent treatment (other than a cleaning):    
I routinely see my dentist every:
3 mo.
4 mo.
6 mo.
12 mo.
Not Routinely
WHAT IS YOUR IMMEDIATE CONCERN?    
Personal History
Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most)?
Yes
No
If yes:
Have you had an unfavorable dental experience?
Yes
No
Have you ever had complications from past dental treatment?
Yes
No
Have you ever had trouble getting numb or had any reactions to local anesthetic?
Yes
No
Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?
Yes
No
If yes:
Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?
Yes
No
Gum and Bone
Do your gums bleed or are they painful when brushing or flossing?
Yes
No
Have you ever been treated for gum disease or been told you have lost bone around your teeth?
Yes
No
Have you ever noticed an unpleasant taste or odor in your mouth?
Yes
No
Is there anyone with a history of periodontal disease in your family?
Yes
No
Have you ever experienced gum recession?
Yes
No
Have you ever had any teeth become loose on their own (without an injury), or do you have diculty eating an apple?
Yes
No
Have you experienced a burning or painful sensation in your mouth not related to your teeth?
Yes
No
Tooth Structure
Have you had any cavities within the past 3 years?
Yes
No
Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
Yes
No
If yes:
Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
Yes
No
Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?
Yes
No
Do you have grooves or notches on your teeth near the gum line?
Yes
No
Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
Yes
No
Do you frequently get food caught between any teeth?
Yes
No
Bite and Jaw Joint
Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
Yes
No
If yes:
Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?
Yes
No
Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?
Yes
No
In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?
Yes
No
Are your teeth becoming more crooked, crowded, or overlapped?
Yes
No
Are your teeth developing spaces or becoming more loose?
Yes
No
Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?
Yes
No
Do you place your tongue between your teeth or close your teeth against your tongue?
Yes
No
Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
Yes
No
Do you clench or grind your teeth together in the daytime or make them sore?
Yes
No
Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?
Yes
No
Do you wear or have you ever worn a bite appliance?
Yes
No
Smile Characteristics
Is there anything about the appearance of your teeth that you would like to change (shape, color, size)?
Yes
No
Have you ever whitened (bleached) your teeth?
Yes
No
Have you felt uncomfortable or self conscious about the appearance of your teeth?
Yes
No
Have you been disappointed with the appearance of previous dental work?
Yes
No
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

PATIENT HIPAA CONSENT FORM

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

  • Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
  • Obtaining payment from third party payers (e.g. my insurance company);
  • The day-to-day healthcare operations of your practice.

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use of disclosure that occurred prior to the date I revoke this consent is not affected.

Patient Name:    
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
Relationship:    

HIPAA Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW DENTAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your dentist, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the dentist's practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a dentist to whom you have been referred to ensure that the dentist has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your dentist's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your dentist. We may also call you by name in the waiting room when your dentist is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, and Organ Donation, Research, Criminal Activity, Military Activity and National Security, Workers' Compensation, Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to object unless required by law.

You may revoke this authorization at any time, in writing, except to the extent that your dentist or the dentist's practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights
Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your dentist is not required to agree to a restriction that you may request. If dentist believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

You may have the right to have your dentist amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

This notice was published and becomes effective on/or before April 14, 2003.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:

 
  
 
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