benyountdds.com - New patient intake forms

New Patient Intake Form
Welcome

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we'll be glad to help you. We look forward to working with you in maintaining your dental health
Patient Information
Name*

First NameInitialLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security #
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Sex*

MaleFemale
Birthdate*

MonthDayYear
Date
Marital Status*

SingleMarriedWidowedSeparatedDivorced
Patient Employed by
Occupation
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone
Please enter a valid phone number.
Business Email
example@example.com
Whom may we thank for referring you?
Notify in case of emergency*
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Business Phone
Please enter a valid phone number.
Email
example@example.com
Primary Insurance
Person Responsible for Account (if different from patient)

First NameInitialLast Name
Relation to Patient (if different from patient)
Birthdate (if different from patient)

MonthDayYear
Date
Address (if different from patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone (if different from patient)
Please enter a valid phone number.
Cell Phone (if different from patient)
Please enter a valid phone number.
Email (if different from patient)
example@example.com
Social Security # (if different from patient)
Person Responsible Employed by (if different from patient)
Occupation (if different from patient)
Business Address (if different from patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone (if different from patient)
Please enter a valid phone number.
Business Email (if different from patient)
example@example.com
Insurance Company
Phone
Please enter a valid phone number.
Insurance Email
example@example.com
Group #
Subscriber #
Name of other dependents under this plan
Is patient covered by additional insurance?

YesNo
Additional Insurance
Subscriber Name

First NameInitialLast Name
Relation to Patient
Birthdate

MonthDayYear
Date
Address (if different from patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Social Security #
Subscriber Employed by
Business Phone
Please enter a valid phone number.
Business Email
example@example.com
Insurance Company
Phone
Please enter a valid phone number.
Insurance Email
example@example.com
Group #
Subscriber #
Name of other dependents under this plan
Signature*

Clear
Date*

MonthDayYear
Date

Office Policies
Patient Name:*
HIPPA Notice of Privacy Practices (See the bottom of this form.)

I have received and have been given the opportunity to review the Notice of Privacy Practices.
Initial:*
Dental Materials Fact Sheet (See the bottom of this form.)

I have received a copy of the Dental Materials Facts Sheet.
Initial:*
Appointment Cancellations Policy

Your appointment time is reserved specifically for you. Other than in an emergency, if you are unable to keep your appointment, please give us 2 business days’ notice. You get plenty of texts, calls and/or emails up to one month before your appointment to allow plenty of time to reschedule. If advance notice is not received a charge may apply.
Initial:*
Insurance/Payment Policy
You are ultimately responsible for the entire cost of your treatment regardless of your insurance coverage. Our office will process insurance claims as a courtesy to you, based on insurance information provided by you. We do everything we can to have an accurate estimate of the patient portion for your treatment. Please note that any estimates given are estimates only and are not guarantee of payment as some restrictions set forth by your insurance camer may apply. Please note that payments for dental services are usually due on the day services are rendered if you don’t have insurance or within 30 days of receipt of a statement from us, unless you have made specific arrangements with our office.
Initial:*
Electronic Communication

Our office uses email and text to communicate with you regarding appointments and office/patient needs. For your privacy, we do not send out detailed dental/health/financial information. I agree to electronic communication with the dental practice at the email/text below. I am aware that there is some risk that unencrypted emails may be viewed by third parties. I am responsible for keeping the email address or cell number on file current and I reserve the right to terminate electronic communication with the office by calling 650-344-7888.
Email Address:
example@example.com
Cell Phone #:
Please enter a valid phone number.
Patient Signature:*

Clear
Date:

MonthDayYear
Date
If Minor: Name of Legal Guardian
Relationship to Patient:
Notice of Privacy Practices

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.

       Office of Ben Yount, DDS

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that health providers keep your medical and dental information private. The HIPAA Privacy Rule states that health providers must also post in a clear and prominent location, and provide patients with, a written Notice of Privacy Practices.

The privacy practices described are currently in effect. We reserve the right to change our privacy practices, and the terms of this Notice, at any time, provided such changes are permitted by law. If changes are made, a new Notice of Privacy Practices will be displayed in our office and provided to patients. You may request a copy of our Notice at any time. Additional information may be obtained from the HIPAA Coordinator listed in our written HIPAA Plan.

USES AND DISCLOSURES OF HEALTH INFORMATION

The following describes how information about you may be used in this dental office:

·         Treatment Services: We may use or disclose your health information to all of our staff members, other dentists, your physicians, and or other health care providers taking care of you.

·         Payment and Health Care Operations: We may use and disclose your health information to obtain payment for services we provide to you, to participate in quality assurance, disease management, training, licensing, and certification programs. Upon your written request, we will not disclose to your health insurer any services paid by you out of pocket.

·         Marketing/Fundraising: We will not use your health information for marketing or fundraising purposes without your written consent. You can opt out of receiving information about our marketing or fundraisers. We will not sell your health information without your explicit authorization.

·         Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders such as voicemail messages, email, postcards, or letters.

·         Legal Requirements: We may disclose your health information when required to do so by law.

·         Abuse or Neglect: If abuse or neglect is reasonably suspected, we may use of disclose your health information to the appropriate governmental authorities.

·         National Security: When required, we may disclose military personnel health information to the Armed Forces. Information may be given to authorized federal officials when required for intelligence and national security activities. Health information for inmates in custody of law enforcement may be provided to correctional institutes.

·         Family Members, Friends, and Others Involved in Care: At your request, we may disclose your health information to a family member or other person if necessary to assist with your treatment and/or payment for services. Based on our judgment and as per 164.522(a) of HIPAA we may disclose your information to these persons in the event of an emergency situation. We also may make information available so that another person may pick up filled prescriptions, medical supplies, records, or x-rays for you. Your information may be disclosed to assist in notifying a family member, caregiver, or personal representative of your location, condition, or death.

·         Business Associates: Some services in our organization are provided through contacts with business associates. Examples include practice management software representatives, accountants, answering service personnel, etc. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we have asked them to do and bill you or your third-party payer for services rendered. All of our business associates are required to safeguard your information and to follow HIPAA Privacy Rules.

·         Workers’ Compensation: We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.

·         Research: We may use or disclose medical information to researchers when an institution’s review board or special privacy board has reviewed the proposed study and established protocols to ensure the privacy of the health information used in their research and determined that the researcher does not need to obtain your authorization prior to using your medical information for research purposes.

·         Public Health Activities: We may disclose medical information for public health activities, to include the following: to prevent or control disease, injury, or disability; to report reactions with medications or problems with products, to notify people of recalls of products they may be using; to notify a person who may have been exposed to a disease or who may be at risk for contracting or spreading a disease of condition; to notify the proper government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence (when required by law).

·         Other Authorizations: In addition to our use of your health information for treatment, payment, or healthcare operations, 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.

·         Breach Notification: We will notify you any time your PHI may have been compromised through unauthorized acquisition, access, use or disclosure.

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 practicably do so. You must make a request in writing to obtain access to your health information.

We will charge you a reasonable cost-based fee for expenses such as copies. If you request X-Rays, there will be a fee for any copies of films. You are not entitled to originals, only copies. Postage will be added if copies are to be mailed. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Details of all fees are available from the HIPAA Coordinator.

·         Accounting of Disclosures: 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, cost-based fee for responding to these additional requests.

·         Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We will keep your information confidential from your health plans if you pay in cash, at your request. In some instances, we may not be 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 to 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 must explain the reason for the amendment.) We may deny your request under certain circumstances.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy policy or have questions or concerns, please contact us. If you have concerns relating to a perceived violation of your privacy rights, to access to your health information, to amending or restricting the use or disclosure of your health information, or to requesting alternative means of communication, you may contact us using the contact information listed at the end of this Notice. You also may submit a written complaint to the Department of Health and Human Services (HHS). We will provide you with the HHS address 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 HHS.

HIPAA Coordinator: Ben Yount, DDS

Telephone: 650-344-7888      Fax: 650-348-1330

Email: BenYountOffice@gmail.com

Address: 720 N. El Camino Real, San Mateo, CA 94401
California Dental Materials Fact Sheet

This California Dental Materials Fact Sheet is provided by the CDA and is required in California to be made available to all new patients and to existing patients once before treatment. Please cross reference the statements made in the CA fact sheet about the World Health Organizations possition on dental mercury with the World Health Organization’s current publication.

What About the Safety of Filling Materials?
Patient health and the safety of dental treatments are the primary goals of California’s dental professionals and the Dental Board of California. The purpose of this fact sheet is to provide you with information concerning the risks and benefits of all the dental materials used in the restoration (filling) of teeth.
The Dental Board of California is required by law* to make this dental materials fact sheet available to every licensed dentist in the state of California. Your dentist, in turn, must provide this fact sheet to every new patient and all patients of record only once before beginning any dental filling procedure. As the patient or parent/guardian, you are strongly encouraged to discuss with your dentist the facts presented concerning the filling materials being considered for your particular treatment.
* Business and Professions Code 1648.10-1648.20

Allergic Reactions to Dental Materials
Components in dental fillings may have side effects or cause allergic reactions, just like other materials we may come in contact with in our daily lives. The risks of such reactions are very low for all types of filling materials. Such reactions can be caused by specific components of the filling materials such as mercury, nickel, chromium, and/or beryllium alloys. Usually, an allergy will reveal itself as a skin rash and is easily reversed when the individual is not in contact with the material. There are no documented cases of allergic reactions to composite resin, glass ionomer, resin ionomer, or porcelain. However, there have been rare allergic responses reported with dental amalgam, porcelain fused to metal, gold alloys, and nickel or cobalt-chrome alloys. If you suffer from allergies, discuss these potential problems with your dentist before a filling material is chosen.

Toxicity of Dental Materials
Dental Amalgam
Mercury in its elemental form is on the State of California’s Proposition 65 list of chemicals known to the state to cause reproductive toxicity. Mercury may harm the developing brain of a child or fetus. Dental amalgam is created by mixing elemental mercury (43-54%) and an alloy powder (46-57%) composed mainly of silver, tin, and copper. This has caused discussion about the risks of mercury in dental amalgam. Such mercury is emitted in minute amounts as vapor. Some concerns have been raised regarding possible toxicity. Scientific research continues on the safety of dental amalgam. According to the Centers for Disease Control and Prevention, there is scant evidence that the health of the vast majority of people with amalgam is compromised. The Food and Drug Administration (FDA) and other public health organizations have investigated the safety of amalgam used in dental fillings. The conclusion: no valid scientific evidence has shown that amalgams cause harm to patients with dental restorations, except in rare cases of allergy. The World Health Organization reached a similar conclusion stating, “Amalgam restorations are safe and cost effective.” A diversity of opinions exists regarding the safety of dental amalgams. Questions have been raised about its safety in pregnant women, children, and diabetics. However, scientific evidence and research literature in peer-reviewed scientific journals suggest that otherwise healthy women, children, and diabetics are not at an increased risk from dental amalgams in their mouths. The FDA places no restrictions on the use of dental amalgam.

Composite Resin
Some Composite Resins include Crystalline Silica, which is on the State of California’s Proposition 65 list of chemicals known to the state to cause cancer.

It is always a good idea to discuss any dental treatment
thoroughly with your dentist.

Dental Materials – Advantages & Disadvantages
DENTAL AMALGAM FILLINGS
Dental amalgam is a self-hardening mixture of silver-tin-copper alloy
powder and liquid mercury and is sometimes referred to as silver
fillings because of its color. It is often used as a filling material and replacement for broken teeth.

Advantages
Durable; long lasting
Wears well; holds up well to the forces of biting
Relatively inexpensive
Generally completed in one visit
Self-sealing; minimal-to-no shrinkage and resists leakage
Resistance to further decay is high, but can be difficult to find in early stages
Frequency of repair and replacement is low

Disadvantages

• Refer to “What About the Safety of Filling Materials”
• Gray colored, not tooth colored
• May darken as it corrodes; may stain teeth over time
• Requires removal of some healthy tooth
• In larger amalgam fillings, the remaining tooth may weaken and fracture
• Because metal can conduct hot and cold temperatures, there may be a temporary sensitivity to hot and cold.
• Contact with other metals may cause occasional, minute electrical flow

COMPOSITE RESIN FILLINGS
Composite fillings are a mixture of powdered glass and plastic resin, sometimes referred to as white, plastic, or tooth-colored fillings. It is used for fillings, inlays, veneers, partial and complete crowns, or to replacement for broken teeth.

Advantages
Strong and durable
Tooth colored
Single visit for fillings
Resists breaking
Maximum amount of tooth preserved
Small risk of leakage if bonded only to enamel
Does not corrode
Generally holds up well to the forces of biting depending on product used
Resistance to further decay is moderate and easy to find
Frequency of repair or replacement is low to moderate

Disadvantages

• Refer to “What About the Safety of Filling Materials”
• Moderate occurrence of tooth sensitivity; sensitive to dentist’s method of application
• Costs more than dental amalgam
• Material shrinks when hardened and could lead to further decay and/or temperature sensitivity
• Requires more than one visit for inlays, veneers, and crowns
• May wear faster than dental enamel
• May leak over time when bonded beneath the layer of enamel

GLASS IONOMER CEMENT
Glass ionomer cement is a selfhardening mixture of glass and organic acid. It is tooth-colored and varies in translucency. Glass ionomer is usually used for small fillings, cementing metal and porcelain/metal crowns, liners, and temporary restorations.

Advantages

Reasonably good esthetics
May provide some help against decay because it releases fluoride
Minimal amount of tooth needs to be removed and it bonds well to both the enamel and the dentin beneath the enamel
Material has low incidence of producing tooth sensitivity
Usually completed in one dental visit

Disadvantages

• Cost is very similar to composite resin (which costs more than amalgam)
• Limited use because it is not recommended for biting surfaces in permanent teeth
• As it ages, this material may become rough and could increase the accumulation of plaque and chance of periodontal disease
• Does not wear well; tends to crack over time and can be dislodged

RESIN-IONOMER CEMENT
Resin ionomer cement is a mixture of glass and resin polymer and organic acid that hardens with exposure to a blue light used in the dental office. It is tooth colored but more translucent than glass ionomer cement. It is most often used for small fillings, cementing metal and porcelain
metal crowns and liners.

Advantages

Very good esthetics
May provide some help against decay because it releases fluoride
Minimal amount of tooth needs to be removed and it bonds well to both the enamel and the dentin beneath the enamel
Good for non-biting surfaces
May be used for short-term primary teeth restorations
May hold up better than glass ionomer but not as well as composite
Good resistance to leakage
Material has low incidence of producing tooth sensitivity
Usually completed in one dental visit
Disadvantages

• Cost is very similar to composite resin (which costs more than amalgam)
• Limited use because it is not recommended to restore the biting surfaces of adults
• Wears faster than composite and amalgam

PORCELAIN (CERAMIC)

Advantages

Very little tooth needs to be removed for use as a veneer; more tooth needs to be removed for a crown because its strength is related to its bulk (size)
Good resistance to further decay if the restoration fits well
Is resistant to surface wear but can cause some wear on opposing teeth
Resists leakage because it can be shaped for a very accurate fit
The material does not cause tooth sensitivity
Disadvantages

• Material is brittle and can break under biting forces
• May not be recommended for molar teeth
• Higher cost because it requires at least two office visits and laboratory services

NICKEL OR COBALT CHROME ALLOYS
Nickel or cobalt-chrome alloys are mixtures of nickel and chromium. They are a dark silver metal color and are used for crowns and fixed bridges and most partial denture frameworks.

Advantages

Good resistance to further decay if the restoration fits well
Excellent durability; does not fracture under stress
Does not corrode in the mouth
Minimal amount of tooth needs to be removed
Resists leakage because it can be shaped for a very accurate fit

Disadvantages

• Is not tooth colored; alloy is a dark silver metal color
• Conducts heat and cold; may irritate sensitive teeth
• Can be abrasive to opposing teeth
• High cost; requires at least two office visits and laboratory services
• Slightly higher wear to opposing teeth

PORCELAIN FUSED TO METAL
This type of porcelain is a glasslike material that is “enameled” on top of metal shells. It is toothcolored and is used for crowns and fixed bridges

Advantages

Good resistance to further decay if the restoration fits well
Very durable, due to metal substructure
The material does not cause tooth sensitivity
Resists leakage because it can be shaped for a very accurate fit

Disadvantages

• More tooth must be removed (than for porcelain) for the metal substructure
• Higher cost because it requires at least two office visits and laboratory services

GOLD ALLOY
Gold alloy is a gold-colored mixture of gold, copper, and other metals and is used mainly for crowns and fixed bridges and some partial denture frameworks
Advantages

Good resistance to further decay if the restoration fits well
Excellent durability; does not fracture under stress
Does not corrode in the mouth
Minimal amount of tooth needs to be removed
Wears well; does not cause excessive wear to opposing teeth
Resists leakage because it can be shaped for a very accurate fit

Disadvantages

• Is not tooth colored; alloy is yellow
• Conducts heat and cold; may irritate sensitive teeth
• High cost; requires at least two office visits and laboratory services

DENTAL BOARD OF CALIFORNIA
1432 Howe Avenue • Sacramento, California 95825
www.dbc.ca.gov
Published by
CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS
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