New Patient FormPlease fill out as much as possible before your first appointment. You must be at least 18 years of age and an Illinois resident. If you referred by someone, what is their name? * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Cell Phone (###) ### #### Home Phone (###) ### #### Work Phone (###) ### #### Preferred Phone Cell Phone Home Phone Work Phone Email Preferred Method of Contact for Appointment Reminders Email Phone Call Sex Male Female Non-Binary Marital Status Single Married Date of Birth MM DD YYYY Do you have dental insurance? Yes No Name of Insurance Company Primary Policy Holder Name Primary Policy Holder Employer Primary Policy Holder Date of Birth MM DD YYYY Member Identification Number Policy Group Number Emergency Contact Name First Name Last Name Phone Number (###) ### #### Relationship Employer Occupation How did you hear about us? Website Insurance Search Engine (Google, Bing, etc.) Referred by Someone Other If you were referred by someone, what is their name? First Name Last Name For your appointments, do you have a preferred time of day or day of the week? Acknowledgement of Late/Broken Appointment Policy A broken appointment is a loss to everyone. Arriving 15 minutes after appointment time or failing to provide notice of cancellation 24 hours or more in advance will result in a late/missed appointment fee of $50 for every missed visit. By accepting, you are acknowledging this office policy. I agree to the Late/Broken Appointment Policy Acknowledgement of Payment Policy For patients without insurance, payment in full for all services is due at the time of visit when services are rendered. For patients with insurance, we will submit claims directly to your insurance on your behalf for the percentage the insurance company will cover. ALL DEDUCTIBLES, COPAY ESTIMATES, NON-COVERED BENEFITS, ETC. MUST BE PAID AT THE TIME THE WORK IS STARTED. Your dental benefit program is a contract between you, your employer, and the insurance company. We are not a party to that contract. This office files your insurance as a courtesy to you. Not all dental services are covered benefits in all contracts, and I understand I am responsible for all fees for services rendered. I understand I am responsible to pay all applicable fees (copay estimates, non-covered benefits, etc.) at the visit services are rendered. I authorize the staff of Everbrite Family Dentistry to perform necessary services needed during diagnosis and treatment with my understanding and consent. I authorize Everbrite Family Dentistry to release any information required to process insurance claims. NOTICE OF PRIVACY PRACTICES (HIPPA) THIS NOTICE DESCRIBES HOW MEDICAL AND DENTAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THE INFORMATION. PLEASE PRINT AND REVIEW CAREFULLY. Everbrite Family Dentistry is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about the privacy practices at Everbrite Family Dentistry please contact: Nicole Forel, D.D.S. , Privacy Officer Effective Date of This Notice: April 14, 2003 I. HOW EVERBRITE FAMILY DENTISTRY MAY USE OR DISCLOSE YOUR HEALTH INFORMATION Everbrite Family Dentistry collects health information from you and stores it in a chart and on a computer. This is your dental record. The dental record is the property of Everbrite Family Dentistry, but the information in the dental record belongs to you. Everbrite Family Dentistry protects the privacy of your health information. The law permits Everbrite Family Dentistry to use or disclose your health information for the following purposes: Treatment: Doctors and staff will need to discuss your health information to treat you safely. Staff helping with your care will need to know about certain health information so they can assist in providing treatment. We may also use or disclose your health information to a physician or other healthcare provider providing treatment to you. Payment: We may use and disclose your health information to obtain payment for services we provide to you. Regular Health Care Operations: Portions of your health information are disclosed for regular health care operations. This might include referrals to specialists which would require that your name and an explanation of the problem be disclosed to an affiliated office. Healthcare operations also include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. Providing Information To You: You may receive a copy of your health information. A reasonable fee will be charged to cover duplication costs. To Your Family And Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. 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 filled prescriptions, medical supplies, x-rays, or other similar forms of health information. Required By Law: As required by law, we may use and disclose your health information. Public Health: As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure. Health Oversight Activities: We may disclose your health information to health agencies during the course of audits, investigations, inspections, licensure and other proceedings. Judicial And Administrative Proceedings: We may disclose your health information in the course of any administrative or judicial proceeding. Law Enforcement: We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena and other law enforcement purposes. Deceased Person Information: We may disclose your health information to coroners, medical examiners and funeral directors. Public Safety: We may disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public. Specialized Government Functions: We may disclose your health information for military, national security, prisoner and government benefits purposes. Worker’s Compensation: We may disclose your health information as necessary to comply with worker’s compensation laws. Marketing: We will not use your health information for marketing communications without your written authorization. Health Plan: We may disclose your health information to the sponsor of your health plan. Change Of Ownership: In the event that Everbrite Family Dentistry is sold or merged with another organization, your health information/record will become the property of the new owner. Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voice mail messages, postcards, or letters). II. WHEN EVERBRITE FAMILY DENTISTRY MAY NOT USE OR DISCLOSE YOUR HEALTH INFORMATION Information: Except as described in this Notice of Privacy Practices, Everbrite Family Dentistry will not use or disclose your health information without your written authorization. If you do authorize Everbrite Family Dentistry to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. Authorization: You may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. III. YOUR HEALTH INFORMATION RIGHTS 1. You have the right to request restrictions on certain uses and disclosures of your health information. Everbrite Family Dentistry is not required to agree to the restriction that you requested. If we deny the request, we will provide you information about the denial and what steps you can take if you disagree. 2. You have the right to receive your health information through a reasonable alternative means or at an alternative location. A request must be made in writing to Everbrite Family Dentistry, which will review the request in a timely manner and inform you of our decision. If we deny the request, we will provide you information about the denial and what steps you can take if you disagree. 3. You have the right to inspect and to request a copy your health information. 4. You have a right to request that Everbrite Family Dentistry amend your health information that is incorrect or incomplete. Everbrite Family Dentistry will consider each request to change your health information. If we deny the request, we will provide you information about the denial and what steps you can take if you disagree. 5. You have a right to receive an accounting of disclosures of your health information made by Everbrite Family Dentistry, except that Everbrite Family Dentistry does not have to account for the disclosures described in parts 1 (Treatment), 2 (Payment), 3 (Regular Health Care Operations), 4 (Providing Information to You), and 14 (Specialized Government Functions) of section I of this Notice of Privacy Practices. 6. You have a right to a paper copy of this Notice of Privacy Practices. If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact the _____________________________ IV. CHANGES TO THIS NOTICE OF PRIVACY PRACTICES Everbrite Family Dentistry reserves the right to amend this Notice of Privacy Practices at any time in the future, and to make the new provisions effective for all information that it maintains, including information that was created or received prior to the date of such amendment. Until such amendment is made, Everbrite Family Dentistry is required by law to comply with this Notice. Revised Notices will be communicated to you at later appointments. V. COMPLAINTS Complaints about this Notice of Privacy Practices or how Everbrite Family Dentistry handles your health information should be directed to Everbrite Family Dentistry. Upon completion of the form that Everbrite Family Dentistry will provide to you, an investigation of your complaint will take place and written notification of the findings will be provided to you. If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to: Department of Health and Human Services _________________________ _________________________ _________________________ _________________________ You may also address your complaint to one of the regional offices for civil rights. A list of these offices can be found online at http://www.hhs.gov/ocr/regmail.html. Acknowledgement of Privacy Practices (HIPPA) I have received a copy of Everbrite Family Dentistry's Notice of Privacy Practices Date MM DD YYYY Thank you!
