New Patient Form: Children

Child Patient Information
Patient's name*

First NameLast Name
Preferred name
Birthdate*

MonthDayYear
Gender*

FemaleMaleGender neutral
Preferred Gender Pronouns
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.
Email*
example@example.com
School
Has any other member of your family been a patient at this office? If so, who?
Who may we thank for referring you?*
Confidential Financial Information
Account Information
Person responsible for account*

First NameLast Name
Relationship to patient*
Birthdate*

MonthDayYear
Soc. Security #
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.
Employer
Email*
example@example.com
If there is an additional person that is responsible for this account, please fill out the following with their information
Person responsible for account

First NameLast Name
Relationship to patient
Birthdate

MonthDayYear
Soc. Security #
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.
Employer
Email
example@example.com
Dental Insurance

Primary Dental Insurance - If there is no dental insurance, then please type N/A
Subscriber's name as it appears on ID card*

First NameLast Name
Relationship to patient*
Birthdate*

MonthDayYear
Soc. Security #
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.
Email*
example@example.com
Employer*
Insurance company name*
Insurance company address*
Subscriber ID#*
Group#
Dental Insurance

Secondary Dental Insurance
Subscriber's name as it appears on ID card

First NameLast Name
Relationship to patient
Birthdate

MonthDayYear
Soc. Security #
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.
Email
example@example.com
Employer
Insurance company name
Insurance company address
Subscriber ID#
Group#
Medical History
Does the patient have any of the following allergies:

LatexMedicineSeasonalFoodMetal
Please specify
Does the patient require premedication for dental visits?*

YesNo
Is the patient pregnant or is there a chance that the patient may be pregnant?*

YesNo
Please check all that apply, including any social, behavioral or developmental information to help us provide your child with the best care

ADHDAIDS/HIVAutismArthritisAsthmaBleeding gumsCancerDiabetesBlood diseaseDizziness/faintingEarachesEpilepsyFrequent headachesImmune disorderHearing impairmentHeart murmurHepatitisMouth breathingTuberculosisVisual impairmentOther
Please explain
Has the patient received their Covid-19 vaccination?*

YesNo
If yes to the previous question, how many doses?

123+
Who is the patient's primary care physician?*
Are there any medications that the patient regularly takes? If so, please list them below:
Dental History
Who is the patient's dentist?*
When was their last dental visit?*

MonthDayYear
Has the patient had any previous orthodontic

EvaluationsTreatment
If so, when?
Is there a history of trauma to the teeth or face?*
Is there a family history of impacted (un-erupted) canines?*
Did either of the patient's parents have any orthodontic treatment?
Please check all that apply to the patient

Bleeding gumsDifficulty chewingSpeech impairmentTeeth grinding/clenchingExtra teethTMJ (jaw joint) pain or clickingThumb/pacifier habit
What is the chief orthodontic complaint?*
What concerns you most when considering orthodontic treatment for your child?

AppearanceCostEffectivenessLength of timePainOther
The information that I have provided is correct, to the best of my knowledge, and I will inform Dr. Steven A. Fischman Orthodontics of any changes. I authorize Dr. Steven A. Fischman Orthodontics to release and request any radiographs or other records, pertaining to my orthodontic treatment, to and from other dental care providers.
Signature of patient (parent or guardian if the patient is a minor)*

Clear
I have received the HIPAA Notice of Privacy Practices (below) for the office of Dr. Steven A. Fischman Orthodontics.
Signature of patient (parent or guardian if the patient is a minor)*

Clear
Notice of HIPAA and Privacy Practices

Please review the following and hit submit at the end
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

If you have any questions about this Notice, please contact our Privacy Officer at the number listed at the end of this Notice. Eachtime you visit a healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and billing-related information. This Notice applies to all of the records of your care generated by your health care provider. Our Responsibilities

Dr. Steven A. Fischman Orthodontics, LLC is required by law to maintain the privacy of your health information and to provideyouwitha description of our legal duties and privacy practices regarding your health information. The current Notice will be posted in the mainreception areaand on our website at centerortho.com The notice will include the effective date. In addition, we will make our best effort to provide you with a copy of this notice that we request you acknowledge with your signature.

We are required by law to abide by the terms of this Notice and notify you if we make changes to this Notice, which may be at any time. Changes to the Notice will apply to your medical information that we already maintain as well as new information receivedafterthechange occurs. If we change our Notice, it will be posted in the main reception area and on our website at centerortho.com You may also request that will a revised Notice be sent to you in the mail or you may ask for one at your next appointment or appropriate visit. This Noticealsoserveto advise you as to your rights with regard to your medical information.

How We May Use and Disclose Medical Information About You The following categories describe examples of the way we use and disclose medical information

ForWe may use medical information about you to provide, coordinate and manage your treatment or services. We may disclose Treatment medicalinformation about you to other doctors, nurses, technicians (e.g. clinical laboratories or imaging companies), medical students, or other personnel who are involved in your care. We may communicate your information either orally or in writing by mail or facsimile.

We mayalso provide a subsequent healthcare provider with copies of various reports that should assist him or her in treating you. For example, your medical information may be provided to a care provider to whom you have been referred so as to ensure that the doctor has appropriate information regarding your previous treatment and diagnosis.

ForPayment We may use and disclose medical information about your treatment and services to bill and collect payment from you, your insurancecompany or a third party payer. For example, we may need to give your insurance company information before it approves or pays for the health care services we recommend for you.

ForHealth Care Operations We may use or disclose, as needed, your health information in order to support our business activities. These activities mayinclude, but are not limited to quality assessment activities, employee review activities, licensing, legal advice, accounting support, information systems support and conducting or arranging for other business activities. In addition, we may also call you by name in the waiting room when your care provider is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment by telephone or reminder card.

BusinessAssociates There are some services provided in our organization through contracts with business associates. Examples include software support. If these services are contracted, we may disclose your health information to our business associate so that they canperform the job that we have asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information through a written contract.

Object Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to

We also may use and disclose your health information as set forth below. You have the opportunity to agree or object to the use or disclosure of all orpartof your health information in these instances. If you are not present or able to agree or object to the use or disclosure of the health information (such as in an emergency situation), then your clinician may, using professional judgment, determine whether the disclosure isin your best interest. In this case, only the information that is relevant to your health care will be disclosed.

IndividualsInvolved in Your Care or Payment for Your Care Unless you object, we may release medical information about you to a friend or family member who is involved in your medical care or who helps to pay for your care. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

FutureCommunications We may communicate to you via newsletters, mailings or other means regarding treatment options, information on health-related benefits or services; to remind you that you have an appointment for medical care; or other community based initiatives or activities in which our facility is participating. If you are not interested in receiving these materials, please contact our PrivacyOfficer.

Otherand Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Object We Permitted useor disclose your health information in the following situations without your authorization or without providing you with an may opportunity to object. These situations include:

As required by law We may use and disclose health information to the following types of entities, including but not limited to: Food and Drug Administration Public Health or Legal Authorities charged with preventing or controlling disease, injury or disability Correctional Institutions
Workers Compensation Agents Organ and Tissue Donation Organizations

Military Command Authorities Health Oversight Agencies Funeral Directors, Coroners and Medical Directors National Security and Intelligence Agencies Protective Services for the President and Others Authority that receives reports on abuse and neglect

Law Enforcement/Legal Proceedings We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena or court order.

State-Specific Requirements Many states have requirements for reporting which may include population-based activities relating to improving health or reducing health care costs, cancer registries, birth defect registries and others.

Your Health Information Rights Although your health record is the physical property of the practice that compiled it, you have therightto:

Inspect and Copy You have the right to inspect and copy medical information that may be used to make decisions about your care. We ask that submityour request in writing. Usually, this includes medical and billing records, but does not include psychotherapy notes or information you compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding. We may deny your request to very limited circumstances. If you are denied access to medical information, you may request that the denial be inspectandcopyincertain reviewed. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review. Requests for access to and copies of your medical information must be submitted to Dr. Steven A. Fischman Orthodontics, LLC inwriting.may be charged up to the maximum amount as prescribed by governing law

If Amendyou feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information by submitting a request in writing. You have the right to request an amendment for as long as we keep the information. We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial.

AnAccounting of Disclosures You have the right to request an accounting of our disclosures of medical information about you except for certaincircumstances, including disclosures for treatment, payment, health care operations or where you specifically authorized a disclosure. Dr.Steven A. Fischman Orthodontics, LLC will provide the first accounting to you in any 12-month period without charge, upon your written request. The cost for subsequent requests for an accounting within the 12-month period will be up to the maximum amount prescribed by governing law.

Request Restrictions You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could askthatwenotuse or disclose information about a procedure that you had. We ask that you submit these requests in writing.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

RequestConfidential Communications You have the right to request that we communicate with you about medical matters in a certain way or certainlocation. We will agree to the request to the extent that it is reasonable for us to do so. For example, you can ask that we use an ata alternative address for billing purposes. We ask that you submit these requests in writing.

APaperCopyof This Notice You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

To exercise any of your rights, please obtain the required forms from the practice and submit your request in writing to the practice'sprivacy officer indicated below.

Complaints If you believe your privacy rights have been violated, you may file a complaint with us by calling (860)236-8376andfor asking Officer the Privacyorby contacting the Secretary of the Federal Department of Health and Human Services by calling 1-800-368-1019, or by theOffice of Civil Rights regional office. All complaints must be also submitted in writing within 180 days of when you knew that contacting the act or omission complained of occurred. You will not be penalized for filing a complaint.

Other Uses of Medical Information Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you mayrevoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasonscovered by your written authorization. However, we are unable to take back any disclosures we have already made with your permission and we are required to retain our records of the care that we provided to you. Privacy Officer: Jo-Anna FischmanTelephone Number: (860)236-8376

Prepared by Total Compliance Solutions, Inc. These procedures are prepared with the understanding that Total Compliance Solutionsandits agents are not engaged in rendering legal, accounting, or other professional services. This information is advisory only. Final interpretationis the responsibility of the regulatory or accrediting body administering the standard or regulation referenced.

Dr. Steven A. Fischman Orthodontics 9 Dale Street
Should be Empty:

Child Patient Information

Confidential Financial Information

Account Information

Dental Insurance

Dental Insurance

Medical History

Dental History

Notice of HIPAA and Privacy Practices