CHILD Patient Paperwork

WELCOME TO OUR OFFICE

So that we might become better acquainted, please complete this entire form.
Patient's Name*
Preferred Name
Nickname
Patient's Social Security*
Birth Date*

MonthDayYear
Gender*
School*
Phone Number*

Area CodePhone Number
Email Address*
example@example.com
Address*

Mailing Address

Street Address Line 2

CityState / Province

Zip
Patient Resides with *
Referred By*
Choose all that apply
Patient Interests*
Please select the option that best describes the orthodontic problem*
PARENTS AND ACCOUNT INFORMATION

If you have any questions in regards to account holder information, please call our office.
Parent's Marital Status*
Father's Name*
Mother's Name*
Father's SS #
Mother's SS #
Father's Phone Number *

Area CodePhone Number
Mother's Phone Number *

Area CodePhone Number
Father's Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Business Phone (extension or department)

Area CodePhone Number
Mother's Business Phone (extension or department)

Area CodePhone Number
Person Responsible for Account Other than parents
Social Security #
Phone Number

Area CodePhone Number
Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
INSURANCE INFORMATION

Our office accepts any dental insurance with orthodontic coverage. We will deduct the insurance amount from the treatment cost.
A dental insurance policy is a contract between the insured and the insurance company. Our professional services are rendered and charged directly to the patient’s account and the patient or person responsible for the account is responsible for payment of all fees incurred. For your convenience, we will gladly assist you in submitting insurance claims pertaining to any charge for care in our office. If you wish assistance, we ask that you provide us with a claim form from your insurance carrier on your first visit or as soon as possible. Otherwise we will assume you are submitting all claims to your insurance carrier and the fees will be due in full from you at time of service or billing.
I will be opting for the Self- Pay option with no insurance included.*

YesNo
Does the patient have a State issued insurance? (Ex: DentaQuest, TennCare, BlueCare, or United HealthCare under patients's name)*

YesNo
Policy Holder Information

I. Primary II. Secondary
Name of insured (Employee)
Name of insured (Employee)
ID #
ID #
DOB
DOB
Employer
Name of the company
Employer
Name of the company
Insurance Co
Insurance Co
Group #
Group #
Ins. Phone #

Area CodePhone Number
Ins. Phone #

Area CodePhone Number
MEDICAL HISTORY

Your answers to the following questions will be helpful in selecting the safest and most effective means of providing your dental care. All information will be kept completely confidential.
Physician’s Name*
Phone Number

Area CodePhone Number
Is your child currently under physician's care?*

NoYes
Has your child experienced or had any major changes to their health problems recently?*

NoYes
Please explain:
Is your child currently taking medications?*

NoYes
List:
Is your child allergic to any Medications, Metals, or Latex?*

NoYes
List:
Has your child received a blood transfusion?*

NoYes
Reason:
Has your child's tonsils or adenoids been removed?*

NoYes
When:
Heart Murmur*

NoYes
Heart Surgery*

NoYes
Rheumatic Fever*

NoYes
Endocrine Disorders*

NoYes
Prolonged Bleeding*

NoYes
Anemia*

NoYes
Blood Disease*

NoYes
Developmental Disorder*

NoYes
Hives/Rash*

NoYes
Hepatitis*

NoYes
Diabetes*

NoYes
Kidney Disease

NoYes
Liver Disease*

NoYes
Tuberculosis*

NoYes
Bronchitis*

NoYes
Asthma*

NoYes
Epilepsy*

NoYes
Fainting*

NoYes
Emotional Problems*

NoYes
Frequent Headaches*

NoYes
Nervous/Anxious

NoYes
Cancer*

NoYes
Bone Disorders*

NoYes
Growth Disorders

NoYes
AIDS*

NoYes
Herpes (fever blisters)*

NoYes
Tonsillitis*

NoYes
Is there any other condition or problem that you think we should know about?
Growth Information for Patients Under 16 Years of Age

Because growth can be an important factor in orthodontic treatment planning, your answers to the following questions are needed to aid in our selection of treatment alternatives:
Has your son or daughter reached puberty?*

NoYes
Girls - Has she started menstruation?

NoYes
When?
Boys - Has his voice changed?

NoYes
When?
Mother's Height
Father's Height
Patient's Height*
Do you feel growth is completed?*

NoYes
Adopted?*

NoYes
Names & Birth dates of patient's brothers & sisters
Have either siblings or parents had orthodontic treatment?*

NoYes
With whom?
DENTAL HISTORY

Please fill out the information below to the best of your ability.
Dentist’s Name:*
Address

Address

Street Address Line 2

CityState

Postal / Zip Code
Phone Number*

Area CodePhone Number
Frequency of dental checkups*
Date of last visit
Is there any unfinished care to be completed with your child's dentist?*

NoYes
Explain:
Is your child frightened about dental treatment?*

NoYes
Explain:
Has your child had an unpleasant experience in a dental office?*

NoYes
Explain:
Has your child had any face or dental injuries?*

YESNO
Explain:
Does your child play any musical instruments?

YESNO
What instrument?
Does you child play sports?*

YESNO
Which sports?
Does your child wear a mouth guard while playing sports?*

NOYes
Have teeth (either primary or permanent) been removed?*

NoYes
Has your child consulted an orthodontist previously?*

NoYes
Whom?
Has your child had any previous orthodontic treatment?*

NoYes
With whom?
Are you satisfied with prior treatment?*

NoYes
Explain:
Is there a history of thumb or finger sucking?*

NoYes
Stopped?
Please check if there is a history of:*

Clenching teethMuscular soreness around head & neckJaw joint sorenessJaw joint popping/clickingGrinding teethHeadaches (more than normal)Excessive snoringRinging in the earsMouth breathing (awake)Mouth breathing (asleep)Speech problemsOther
If speech problems, which sounds?
Is there any other information that may be helpful?
I, the undersigned, have given the above dental and medical information, have reviewed it, and find it accurate. If there are any changes to this record, I will inform this practice.
Parent's Name*
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in the notice while it is in effect. This notice takes effect September 1, 2013 and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of the notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and make the notice available upon request.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to another healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you. Tennessee/Georgia law states that the parent or guardian who accompanies the child is responsible for payment of services regardless of divorce decree. In the event you should pay in full for a service out of pocket you have the right to request our office not to disclose treatment information for this service to your health plan.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluation practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operation, you may give us written authorization to use your information or to disclose it. 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 the notice.

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 and 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 with your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable assumptions of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Marketing Health Related Services: We will not use your health information for marketing communications without your written authorization. If your PHI is used for fundraising you have the option to opt out at any time.

Required By Law: We may use or disclose your health information when we are required to do so by law.

Abuse Or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence of the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials, health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to a correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemails, emails, text messages, postcards, or letters).
PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot do so. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this notice. We will not charge you for expenses such as copies and staff time. You have the right to an electronic copy of your records.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations, and certain other activities for the last 6 years. If you request this accounting more than once in a 12-month period, we may charge you a reasonable costs-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restriction on your use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or alternative locations. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.

Breach Notification: It is our obligation to notify you in the event of a breach of unsecured PHI.

Electronic Notice: If you receive this notice on our web-site or by electronic mail (email), you are entitled to receive this notice in written form.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights or you disagree with a decision we made about your access to your health information in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of the notice. You may also submit a written complaint to the U.S. Department of Health and Human Services. We support your right to the privacy of your health information. No retaliation will occur against you for filing a complaint.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

(You may refuse to sign this acknowledgement)
I, blanks* , have received a copy of this office's Notice of Privacy Practices.
Date*

MonthDayYear
Date
Parent's Signature*

Clear
Should be Empty:

WELCOME TO OUR OFFICE

PARENTS AND ACCOUNT INFORMATION

INSURANCE INFORMATION

Policy Holder Information

MEDICAL HISTORY

DENTAL HISTORY

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES