Dental History Form

Tomas Anderkvist D.D.S
New Patient Information
Westwood Dental Smiles

Dental Insurance

Primary Carrier

Insurance co. name
Insurance co. phone

Address (Street)

City
State
ZIP

Group no. (Plan or Policy no.)
Insured's I.D. no.

Insured's name
Relationship to patient

Date of birth
Insured social security no.

Insured employer name
Is insured a patient in our practice?
Yes No

Secondary Carrier

Insurance co. name
Insurance co. phone

Address (Street)

City
State
ZIP

Group no. (Plan or Policy no.)
Insured's I.D. no.

Insured's name
Relationship to patient

Date of birth
Insured social security no.

Insured employer name
Is insured a patient in our practice?
Yes No

Person Financially Responsible for Account

Name
Relationship to patient

Social security no.
Phone

Drivers license no.
Date of birth

Address (Street)

City
State
ZIP

Employer
Work phone

Preferred payment method
Cash Credit Card

Visa/MC/AMEX no.
Exp. date

If patient is a minor, name of parent or legal guardian and relationship

Is insured a patient in our practice?
Yes No

Payment is due in full at the time of treatment

(Unless prior arrangements have been approved)

I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the dental office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize release of any information including the diagnosis and records of treatment or examination rendered, to my insurance company.

I the undersigned, hereby authorize the office listed below to charge my credit card for charges not covered on the insurance. I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective healthcare provider or agency that may release such information to you. I will notify the dentist of any changes in my health or medication.

Signature
Date

Person to contact in case of emergency

Name
Relationship to patient

City
State
Cell Phone

Home Phone
Work Phone

- OFFICE USE ONLY
- I VERBALLY REVIEWED THE MEDICAL/DENTAL INFORMATION ABOVE WITH THE PATIENT NAMED HEREIN.
- Date
- Initials

HIPAA Privacy Rule of Patient Authorization Agreement

Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a))

I, (Patient's Name) understand that as part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as:

• a basis for planning my care and treatment;

• a means of communication among the health professionals who may contribute to my health care;

• a source of information for applying my diagnosis and surgical information to my bill;

• a means by which a third-party payer can verify that services billed were actually provided;

• a tool for routine health care operations such as assessing quality and reviewing the competence of health care professionals.

I have been provided with a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures.

I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review this facility's notice prior to signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me.

Privacy Rule of Patient Consent Agreement

Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.506(a))

I understand that:

• I have the right to review this facility's Notice of Information practices prior to signing this consent;

• that this facility reserves the right to change the notice and practices and that prior to implementation will mail a copy of any notice to the address I've provided, if requested;

• I have the right to object to the use of my health information for directory purposes;

• I have the right to request restrictions as to how my Protected Health Information may be used or disclosed to carry out treatment, payment, or healthcare operations, and that this facility is not required by law to agree to the restrictions requested;

• I may revoke this consent in writing at any time, except to the extent that this facility has already taken action in reliance thereon.

Signature of Patient or Legal Representative Witness:

Printed Name of Patient or Legal Representative Witness:

Date:

HIPAA Privacy Rule Receipt of Notice of Privacy Practices Written Acknowledgement Form

Acknowledgement of Receipt of Information Practices Notice (§164.520(a))

I, (Patient's Name) understand that as part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I acknowledge that I have been provided with and understand this facility's Notice of Privacy Practices provides a complete description of the uses and disclosures of my health information. I understand that:

• I have the right to review this facility's Notice of Privacy Practices prior to signing this acknowledgment;

• this facility reserves the right to change their Notice of Privacy Practices and prior to implementation of this will mail a copy of any revised notice to the address I've provided, if requested.

Signature of Individual or Legal Representative Witness:

Printed Name of Individual or Legal Representative Witness:

Date:

FOR OFFICE USE ONLY

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but it could not be obtained because:

• Individual refused to sign

• Communication barrier prohibited obtaining the acknowledgement

• An emergency situation prevented us from obtaining acknowledgement

• Other (please specify)

Privacy Official:

Date:

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