Patient Information

Patient's full name:
 
 
Prefers to be called:
Patient's Address:
 
 
 
 
Home Phone:
Cell Phone:
Email:
Patient's Birthday:
Age:
Patient's Dentist:
Favorite Hobbies:
Whom may we thank for referring you?
School:
Name(s) and age(s) of siblings:
Other family members seen by us:

Responsible Party Information

Full name:
 
 
Home Address:
 
 
 
 
No. of years at address:
Employer:
Social Security Number:
Occupation:
Work Phone:
Spouse's Name:
Email:
Spouse's Employer:
Work Phone:
Spouse's Occupation:
Cell Phone:
Birthdate:
Spouse's SSN:

Primary Dental Insurance Information

Insured's Name:
Insured's SSN:
Insured's Employer:
Insured's Birthday:
Insurance Company Name:
Insurance Phone #:
Insurance Company Address:
Group Number:
ID Number:
Relationship to patient:

Medical History

(please check if patient has, or has had...)
Please explain all checked responses:
List any allergies:
List any medications:
Have you ever been told you need to pre-medicate before a dental apppointment?

Dental History

(please check if patient has, or has had...)
   
 
 
Please explain all checked responses:
Please list your chief concern(s) and what you would like treatment to accomplish:
Has patient ever been by any previous orthodontist? If yes, complete below.
Orthodontist:
Last seen:
Address:
Treatment Started:

Notice of Privacy Practices for Protected Health Information

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 PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

This Notice is provided to you in compliance with the requirements of the Health Insurance Portability and Accountability Act, referred to as "HIPAA". We understand that medical information about you and your health is personal "Protected Health Information" ("PHI") and we are committed to protecting your medical information. PHI includes individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for such health care provided to you.

USES AND DISCLOSURES OF HEALTH INFORMATION

Treatment:Treatment: We may use and disclose your PHI to your insurance provider, your dentist and other dental care providers for treatment purposes. This includes the coordination or management of your health care with a third party.

Payment:We may use and disclose your PHI in order to fulfill our duty to check your coverage, determine your benefits, and secure payment for services we provide to you.

Health Care Operations:We may use and disclose your PHI in order to carry out administrative functions. These activities include, but are not limited to, quality assessment and improvement activities, reviewing the competence or qualification of health care professionals, conducting training programs, accreditation, certification, and licensing or credentialing activities. We may use a sign-in sheet at the registration desk where you will be asked to sign your name or state it aloud. We may also call you by name in the waiting room when we are ready to see you. We may contact you to remind you of a scheduled appointment via email messages, voicemail messages, text messages, postcards, or letters.

Persons Involved In Care:We may disclose your PHI to a family member or other person involved in your treatment to the extent necessary to help with your health care. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up dental supplies, x-rays, or other similar forms of health information.

Required by Law:We may use or disclose your PHI to the extent that such use or disclosure is required by law. We may disclose your PHI without your authorization for public health purposes, auditing purposes, research studies, and emergencies.

Patient Rights Access:In most cases, you have the right to view or get a copy of your PHI. You also have the right to receive a list of instances in which your health information was disclosed for purposes other than treatment, payment, or health care operations. Under HIPAA, you do not have the right to inspect or copy information compiled in reasonable anticipation of, or for use in, a civil, criminal or administrative action or proceeding, or information that we are otherwise prohibited by law from disclosing.

You may request that we not use or disclose your PHI for treatment, payment, or health care operations except when required by law, or in emergency circumstances. We will consider your request but are not legally required to accept it. You also have the right to receive confidential communications of your PHI by alternative means or at an alternative location. We will accommodate all reasonable requests, but certain conditions may be imposed. All requests must be submitted in writing to our office.

Questions and Complaints:If you want more information about our privacy practices or have questions or concerns, please contact us. You may complaint to us or to the U.S. Department of Health and Human Services in writing if you believe that your privacy rights have been violated. You may file a complaint with us by notifying our office of your complaint. We will not retaliate against you for filing a complaint.

Our Contact Information: Lepley Orthodontics, 17177 Preston Rd., Suite #130, Dallas, TX 75248 (972)735-9000

We are required by law to maintain the privacy of your health information. Protection of patient privacy is important to us. This notice summarizes the privacy practices that will be followed by Casey R. Lepley, DMD MS, DBA: Lepley Orthodontics.

SIGNATURE:
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