VFD_JULY21 New Patient Paperwork

PATIENT MEDICAL RECORD
Name*

First NameLast Name
Middle initial
Date of Birth*

MonthDayYear
Date
What is your general state of health?*

ExcellentGoodFairPoor
Please select the answer that applies to you:*

I do have a primary care physician, information below.I do have a primary care physician, but can't remember their information.I do not have a primary care physician.
Primary Physician Name
Physician Address Street Address City State Zip
Physician Phone Number
Please enter a valid phone number.
Specialist Type   Type
Specialist Name   Name
Specialist Address
   Street Address   City   State   Zip
Specialist Phone Number
Please enter a valid phone number.
Specialist Type   Type
Specialist Name   Name
Specialist Address
   Street Address   City   State   Zip
Specialist Phone Number
Please enter a valid phone number.
Have you been under a physician's care during the last two years?   *
Have you been treated in a hospital in the past three years? If yes, what   *
Have you had major surgery If yes, what?   *
History with general or IV anesthesia?   *
Have you ever taken drugs for osteoporosis/penia?    *
If female: Are you pregnant or nursing?    *
Do you have any food allergies? If yes, what     *
Has it ever been recommended that you take antibiotics prior to dental visits?    *

Do you or have you had any of the following below?*

	Present	Past	None
Heart Disease
Heart Failure
Angina
Mitral Valve Prolapse
Rheumatic Fever
Congenital Heart Lesion
Artificial Heart Valves
Stent
Heart Surgery
Pacemaker
High Blood Pressure
Stroke
Diabetes
Bleeding Problems/ Bruises
Hemophilia
Anemia/ Sickle Cell
Leukemia
HIV+/ AIDS
Fainting/ Dizzy Spells
Lung Disease
Asthma
Emphysema/ Bronchitis
Tuberculosis/ PPD+
Cancer
Radiation Therapy
Chemotherapy
Kidney Disease
Liver Disease
Hepatitis A, B
Hepatitis C
Acid Reflux/ GERD
Stomach Ulcer
Autoimmune Disease
Thyroid Disease
Fibromyalgia
Arthritis
Osteoporosis/ Penia
Psychiatric Disorder
Epilepsy/ Seizures
Cerebral Palsy
Codeine Allergy
Novocaine Allergy
Aspirin Allergy
Sulfa Allergy
Latex Allergy
Penicillin Allergy

Do you have any condition, disease or problem not previously listed? *
Are you allergic to any medications not listed above? If so which:*
Please list all the medications you are taking, including over the counter drugs and herbs: (List medication, Dosage, and Reason) (If none write N/A)
Signature of patient/parent/guardian*

Clear
Date*

MonthDayYear
Date

PATIENT REGISTRATION
CONTACT INFORMATION
Name*

First NameLast Name
Middle Initial
Sex

MaleFemale
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Work Ext.
Social Security #
Email Address
example@example.com
Preferred Number*

CellHomeWork
Marital Status
Spouses' Name (If applicable)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Occupation
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
REFERRAL INFORMATION
How did you find out about our office?
Who may we thank for referring you to our practice?
Reason for choosing Verber Family Dentistry?
RESPONSIBLE PARTY (IF OTHER THAN PATIENT)
Name

First NameLast Name
Sex

MaleFemale
Relationship to Patient
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Work Ext.
Email
example@example.com
INSURANCE INFORMATION
Please select one of the two answers:*

I do have active dental insurance, information filled out below.I do not have dental insurance.
Primary Carrier

If applicable
Insured Name
Birthday
Insured's Employer
Insured Soc. Sec. #
Group #
Insurance Company
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Co. Phone
Secondary Carrier

(If you have double coverage)
Insured Name
Birthday
Insured's Employer
Insured Soc. Sec. #
Group #
Insurance Company
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Co. Phone
Our goal is to provide you with extraordinary care and service. Is there anything we can do to give you the best experience?
Signature of patient, parent or guardian*

Clear
Date*

MonthDayYear
Date
Relationship to Patient

RELEASE & PHOTO IMAGE PUBLICATION CONSENT VERIFICATION AGREEMENT
Verber Family Dentistry is dedicated to improving standards of care through the delivery of extraordinary treatment, research, and sharing of expertise. This photo release allows us to lecture, teach, publish and learn in the pursuit of dental excellence. If you have any questions or concerns with this agreement please feel free to discuss them with a treatment coordinator or your dentist prior to signing.
Patient Name*
This AGREEMENT is for the purpose of identifying any express or implied agreement, including, but not limited to, permission, consent, release, and/or authorization between DOCTOR/PRACTICE and PATIENT in connection with the medical services PATIENT received from DOCTOR/PRACTICE.

DOCTOR/PRACTICE and PATIENT warrant and represent that PATIENT has given CONSENT and FULL AUTHORIZATION that any photographs and/or images of PATIENT, under the following conditions.

1. The photographs and/or images & videos will be taken by DOCTOR/PRACTICE or by a photographer and/or skilled operator approved by DOCTOR/PRACTICE.

2. The photographs and/or images may be used for:

a. Identification purposes, medical records, and if in the judgment of DOCTOR/PRACTICE, medical research, education or science will be benefited by their use. Such photographs and/or images and information relating to PATIENT may be published or republished, either separately or in connection with each other, in but not limited to, professional journals, medical books, medical-based Internet websites, or any other purpose which DOCTOR/PRACTICE may deem proper in the interest or, but not limited to, medical education, knowledge, or research; and or

b. PATIENT further authorizes that the photographs and/or images may be used by DOCTOR/PRACTICE or by an entity approved by DOCTOR/PRACTICE in promotional printed, computer website and/or video material.
Check one:*

OK to use full face images for promotional & video materialPlease refrain from using full face images in promotional material
3. At no time will PATIENT'S name, address, or any other alpha/numeric PATIENT identifiable information be used in connection with the publication of the photographs and/or images of PATIENT. PATIENT acknowledges the possibility that his/her identity may become known as a result of the publication and use of the photographs and/or images described in paragraph 2; above.

4. The photographs and/or images & video may be modified and/or retouched in any way in DOCTOR'S/PRACTICE discretion.

By signing below, PATIENT certifies that he/she has read and understood each and every section of this Agreement, and agrees to be bound by its terms.
Patient Signature*

Clear
DATE*

MonthDayYear
Date

INSURANCE AGREEMENT
Dear Patient,

We have prepared this letter to help you better understand the complexities of dental insurance. We realize how confusing it can be. To begin, we would like to highlight a misconception--dental insurance is not designed to pay for all dental care. Most contracts have limits and/or various degrees of co-payment. However, at Verber Family Dentistry, we are committed to working with you and your insurance company in order to provide the best and most affordable treatment.

All levels of payment by insurance companies, including allowed fees and UCR's (usual and customary rates), are governed by the premiums they are paid. They do not reflect actual dental costs. Our fees are based upon a combination of our costs, our time, and our constant dedication to supplying our patients with the highest quality dental care. The treatment recommended by our office is never based on the restraints of your insurance contract.

It should be understood that the dental insurance contract is between the insurance company and the patient, whom bears the ultimate financial responsibility. All estimated co-pays for treatment performed at our office is due at the time of service.

We hope this information has been helpful. Please take the time to review your insurance contract thoroughly so we may best serve you. As always, you may feel free to ask any member of our staff for clarification on services, billing, and insurance.
*

I do not have insuranceI have insurance and agree
Patient Name (Printed)*
Date*

MonthDayYear
Date
Patient Signature*

Clear

NOTICE OF PRIVACY PRACTICES PATIENT ACKNOWLEDGEMENT
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.

We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 09/23/2013, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time provided such changes are permitted by applicable law, and to make new Notice provisions effective for all protected health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new Notice upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

We may use and disclose your health information for different purposes, including treatment, payment, and health care operations. For each of these categories, we have provided a description and an example. Some information, such as HIV-related information, genetic information, alcohol and/or substance abuse records, and mental health records may be entitled to special confidentiality protections under applicable state or federal law. We will abide by these special protections as they pertain to applicable cases involving these types of records.

Treatment. We may use and disclose your health information for your treatment. For example, we may disclose your health information to a specialist providing treatment to you.

Payment. We may use and disclose your health information to obtain reimbursement for the treatment and services you receive from us or another entity involved with your care. Payment activities include billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your dental health plan containing certain health information.

Healthcare Operations. We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, conducting training programs, and licensing activities.

Individuals Involved in Your Care or Payment for Your Care. We may disclose your health information to your family or friends or any other individual identified by you when they are involved in your care or in the payment for your care. Additionally, we may disclose information about you to a patient representative. If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information.

Disaster Relief. We may use or disclose your health information to assist in disaster relief efforts.

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

Public Health Activities. We may disclose your health information for public health activities, including disclosures to: prevent or control disease, injury or disability; report child abuse or neglect; report reactions to medications or problems with products or devices; notify a person of a recall, repair, or replacement of products or devices; notify a person who may have been exposed to a disease or condition; or notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.

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 correctional institution or law enforcement official having lawful custody the protected health information of an inmate or patient.

Secretary of HHS. We will disclose your health information to the Secretary of the U.S. Department of Health and Human Services when required to investigate or determine compliance with HIPAA.

Worker’s Compensation. We may disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.

Law Enforcement. We may disclose your PHI for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order. Health Oversight Activities. We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Judicial and Administrative Proceedings. If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about the request or to obtain an order protecting the information requested.

Research. We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information.

Coroners, Medical Examiners, and Funeral Directors. We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties.

Fundraising. We may contact you to provide you with information about our sponsored activities, including fundraising programs, as permitted by applicable law. If you do not wish to receive such information from us, you may opt-out of receiving the communications.

OTHER USES AND DISCLOSURES OF PHI

Your authorization is required, with a few exceptions, for disclosure of psychotherapy notes, use or disclosure of PHI for marketing, and for the sale of PHI. We will also obtain your written authorization before using or disclosing your PHI for purposes other than those provided for in this Notice (or as otherwise permitted or required by law You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization.

YOUR HEALTH INFORMATION RIGHTS

Access. You have the right to look at or get copies of your health information, with limited exceptions. You must make the request in writing. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice. If you request information that we maintain on paper, we may provide photocopies. If you request information that we maintain electronically, you have the right to an electronic copy. We will use the form and format you request if readily producible. We will charge you a reasonable cost-based fee for the cost of supplies and labor of copying, and for the postage if you want copies mailed to you. Contact us using the information listed at the end of this Notice for an explanation of our fee structure. If you are denied a request for access, you have the right to have the denial reviewed in accordance with the requirements of applicable law.

Disclosure Accounting. With the exception of certain disclosures, you have the right to receive an accounting of disclosures of your health information in accordance with applicable laws and regulations. To request an accounting of disclosures of your health information, you must submit your request in writing to the Privacy Official. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to the additional requests.

Right to Request a Restriction. You have the right to request additional restrictions on our use or disclosure of your PHI by submitting a written request to the Privacy Official. Your written request must include (1) what information you want to limit, (2) whether you want to limit our use, disclosure or both, and (3) to whom you want the limits to apply. We are not required to agree to your request except in the case where the disclosure is to a health plan for purposes of carrying out payment or health care operations, and the information pertains solely to a health care item or service for which you, or a person on your behalf (other than the health plan), has paid our practice in full.

Alternative Communication. You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. You must make your request in writing. Your request must specify the alternative means or location, and provide a satisfactory explanation of how payments will be handled under the alternative means or location you request. We will accommodate all reasonable requests. However, if we are unable to contact you using the ways or locations you have requested we may contact you using the information we have.

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. If we agree to your request, we will amend your record(s) and notify you of such. If we deny your request for an amendment, we will provide you with a written explanation of why we denied it and explain your rights.

Right to Notification of a Breach. You will receive notifications of breaches of your unsecured protected health information as required by law.

Electronic Notice. You may receive a paper copy of this Notice upon request, even if you have agreed to receive this Notice electronically on our Web site or by electronic mail (e-mail

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 if you disagree with a decision we made about access to your health information or 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 this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Our Privacy Official: Dr. Michael Verber

Phone: 717.737.4337 Fax: 717.737.4337

Address: 3920 Market Street, Camp Hill, PA 17011

Email: dr.verber@verberdental.com
I had the opportunity to review and/or obtain a copy of this office's Notice of Privacy Practices.
Print Name*
Date of Birth*

MonthDayYear
Date
Signature

Clear
Relationship to patient (if signed by personal representative of patient):
Date*

MonthDayYear
Date
If we are able to leave a message with medical & financial information on phone numbers please check yes or no*

YesNo
Please list an individual's names that we are allowed to release financial and medical information to, if none write "none":
Name
* You May Refuse to Sign This Acknowledgment*

Verber Family Dentistry-Consent to treat a minor/child
Is the patient a minor?*

YesNo
In providing dental care, we will treat your child as we would our own. Periodontal & oral surgery procedures are an important health service for your child, and it is our goal to provide him/her with a satisfying experience in our office. Please read this form carefully. Should you have any questions, our office staff will be delighted to help you.

1. I hereby authorize and direct doctors and staff at Verber Family Dentistry to perform dental treatment with the use of any necessary or advisable radiographs (x-rays) and/or any other diagnostic aids in order to complete a thorough diagnosis and treatment plan. I understand certain parts of the treatment may be performed by dental assistants and hygienists.

2. I understand x-rays, photographs, models of the mouth, and/or any other diagnostic aid used for an accurate diagnosis and treatment planning are the property of the doctor, but copies are available upon request.

3. In general terms, the dental procedure(s) can include but not be limited to comprehensive oral examination, radiographs, cleaning of the teeth and the application of topical fluoride, application of sealants to the grooves of the teeth, treatment of diseases or injured teeth with dental restorations, stainless steel or composite crowns and/or root canal treatment, oral surgery, extraction of one or more teeth, excision of hyperplastic and/or pericoronal tissue, exposure of unerupted tooth, placement of space maintainers and/or replacement of missing teeth with dental prosthesis, treatment of diseases or injured oral tissues secondary to traumatic injuries and/or accidents and/or infection, treatment of habits, malposed (crooked) teeth, orthodontics and/or oral dental development or growth abnormalities

4. I authorize the use of accepted behavior management techniques including nitrous oxide analgesia in order to complete treatment for my child. I understand that the doctor is not responsible for previous dental treatment. I understand that in the course of treatment, this previously existing dentistry may need adjustment and/or replacement. I realize that guarantees of results or absolute satisfaction are not possible in dental health services.

5. I have answered all the questions about me or my dependent's medical history and present health condition fully and truthfully. I have told the dentist or other office personnel about all conditions, including allergies, which might indicate that my child should receive oral medications. I also understand if I or my dependent ever had any changes in health status or any changes in medication(s) I will inform the doctor at the next appointment.

6. I authorize other individuals with whom I have places the care of my child, such as other family members, caregivers to sign consent for dental treatment for my child should they bring my child to any future appointments.

I hereby acknowledge that I have read & understand this consent and the meaning of its contents. All questions have been answered in a satisfactory manner and I believe I have sufficient information to give informed consent for treatment. I further understand that this consent shall remain in effect until terminated by me.
Patient's Name
Date

MonthDayYear
Date
Parent/Guardian
Relationship to Patient
Should be Empty:

	1	2	3	4	5
Preventative Care
Overall Wellness
Extraordinary Service
Freedom from Pain
Cost & Affordability
Appearance of Smile
Extraordinary Quality of Treatment
Avoiding Dentures/ Removable Teeth

	Present	Past	None
Sensitive Teeth
Bleeding Gums
Bad Breath
Loose Teeth
Clenching / Grinding
Orthodontic Treatment
Perio Treatment
Smoking/ Tobacco
Oral Surgery/ Extractions
Dental Implants
Cold Sores
Freq. Sugary Drinks/ Juices

PATIENT MEDICAL RECORD

PATIENT REGISTRATION

CONTACT INFORMATION

REFERRAL INFORMATION

RESPONSIBLE PARTY (IF OTHER THAN PATIENT)

INSURANCE INFORMATION

Primary Carrier

Secondary Carrier

DENTAL HEALTH RECORD

Dental History

Aesthetics

TMJ

Sleep

RELEASE & PHOTO IMAGE PUBLICATION CONSENT VERIFICATION AGREEMENT

INSURANCE AGREEMENT

NOTICE OF PRIVACY PRACTICES PATIENT ACKNOWLEDGEMENT

Verber Family Dentistry-Consent to treat a minor/child