Patient Information & HIPAA Form

Patient Information & HIPAA Form
Patient Name *
Email *
example@example.com
DOB *

Month Day Year
Date
Sex *

Male Female
Identifies As
Cell Phone *

Area Code Phone Number
Alternative Phone

Area Code Phone Number
Social Security #
Have we treated any family members?
Who can we thank for referring you to our office?
I prefer to be seen in your:

Lawrence Office Topeka Office Baldwin Office
School
Hobbies
Who will be financially responsible for this account? *

Self Parent StepParent Grandparent
Name (If different from above)
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Social Security #
Driver's License #
Employer
Years Employed
Parent / Spouse 1
Name
Address (If different from above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
DOB

Month Day Year
Date
Social Security #
Phone Number

Area Code Phone Number
Email
example@example.com
Employer
Years Employed
Parent 2
Name
Address (If different from above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
DOB

Month Day Year
Date
Social Security #
Phone Number

Area Code Phone Number
Email
example@example.com
Employer
Years Employed
Insurance Information
Policy Holder
DOB

Month Day Year
Date
Policy Holder’s Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Member ID/ Social Security #
Name of Insurance Company
Employer
2nd Insurance Policy ( Even if there is no orthodontic benefit, please fill out)
Policy Holder
DOB

Month Day Year
Date
Policy Holder’s Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Member ID/ Social Security #
Name of Insurance Company
Employer
NOTICE: DO NOT SIGN THIS AGREEMENT BEFORE YOU READ AND AGREE TO THE CONDITIONS ABOVE. YOU ARE ENTITLED TO A COPY OF THIS AGREEMENT AT THE TIME YOU SIGN.
HIPAA RELEASE AND WAIVER

(Guide to Patient Privacy Rules Is in Waiting Room)
Signature For Health History

I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.
Patient/Responsible Party Signature *

Clear
Responsible Party Name *
Date *

Month Day Year
Date
Should be Empty:

Patient Information & HIPAA Form

Parent / Spouse 1

Parent 2

Insurance Information

HIPAA RELEASE AND WAIVER

Signature For Health History