Adult Registration

Patient Name *

First Name Last Name
Gender *

Male Female
Social Security #
Required for insurance verification
Birth Date *

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Phone *

Area Code Phone Number
Primary Phone Type
Secondary Phone

Area Code Phone Number
Secondary Phone Type
E-mail *
Employer's Name
Occupation
Marital Status

Single Married Divorced
Spouse/Partner's Name
Emergency Contact's Name
Phone Number

Area Code Phone Number
Relation

Dental Insurance
Do You have Dental Insurance? *
Primary Insurance Company
Phone Number
Group Number
Subscriber ID
Policy Holder's Name
Policy Holder's Birth Date

Month Day Year
Relation
Employer
Work Phone #

Area Code Phone Number
________________________________________
Secondary Insurance Company
Phone Number
Group Number
Subscriber ID
Policy Holder's Name
Policy Holder's Birth Date

Month Day Year
Relation
Employer
Work Phone #

Area Code Phone Number

Records Consent
I consent to allow the orthodontist and staff members at Kottemann Orthodontics to take orthodontic "Records" if indicated. This includes but is not limited to a Panoramic Radiograph, Cephalometric Radiograph, Digital Scan and Photos.
Signature *

Clear
Date

Month Day Year

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES & CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION PATIENT
TO THE PATIENT – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out our treatment, payment activities and healthcare operations. Notice of Privacy Practice: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we may make of your protected health information, and other important matters about your protected health information. A copy of our Notice of Privacy Practices accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices which will contain the changes. These changes may apply to any of your protected health information that we maintain.

You may obtain another copy of our Notice of Privacy Practices, including revisions, at any time by contacting:

Privacy Officer : Anna

Telephone: 763-420-6834

Fax: 763-4205634

13998 Maple Knoll Way, Suite 102

Maple Grove, MN 55369

Consent Does Not Expire after One Year. By signing this Consent form, I am explicitly giving informed consent for the release of health records and health information for the purposes listed herein and that this Consent does not expire after one year for 1) the release of health records to a provider who is being advised or consulted with in connection with the releasing provider’s current treatment of myself; or, 2) the release of health records to an accident and health insurer, health service plan corporation, health maintenance organization, or third-party administrator for purpose of payment of claims, fraud investigation, or quality of care review and studies.

Right to Revoke: You have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Privacy Officer listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or continue treating you if you revoke this Consent. You may obtain a revocation of consent form upon request.

Signature: I have received a copy of this practice’s Notice of Privacy Practices and have had the full opportunity to read and consider the contents of this Consent form. I understand that by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.
Signature *

Clear
Date

Month Day Year

v I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.

v I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

v I understand that where appropriate, credit bureau reports may be obtained.
Signature *

Clear
Date

Month Day Year
Should be Empty:

Dental Insurance

Dental History

Health History

Records Consent

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES & CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION PATIENT