www.fortlauderdaledentistry.com - Patient Registration

Patient Registration
Patient Information
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Date*

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Nickname
Address

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CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Mobile Phone Number*

Area CodePhone Number
Other Numbers
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What would you like for us to pray for you?
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Date
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Gen. PhysicianOncologistAlternative Med. (Holistic)CardiologistChiropractorOther
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Alternative Care doctor
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Cardiologist
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Endocrinologist
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Office Number

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Chiropractor
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Date
Address

City, State

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Number

Area CodePhone Number
Oncologist
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Date
Address

City, State

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Number

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Neurologist
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Date
Address

City, State

Street Address Line 2

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Postal / Zip Code
Office Number

Area CodePhone Number
Physical Therapist
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MonthDayYear
Date
Address

City, State

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Number

Area CodePhone Number
Acupuncturist
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Address

City, State

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Notice of Privacy Practices - August 1, 2013

The International Center For Dental Excellence - Dr. Yolanda Cintron D.M.D., P.A.
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

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and controls your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present, and future physical, dental or mental health condition and related health care services.

If we have HIV or substance abuse information about you, we cannot release that information without a special signed, written authorization from you. This is different than the authorization and consent mentioned above. In order to disclose these types of records for purposes of treatment, payment or health care operations, we will have to have both your signed Consent and a special written authorization that complies with the law governing HIV or substance abuse records.

Individual Rights

You have the right to inspect and copy your health information, such as medical and billing records, that we use to make decisions about your care. In order to do so, you must submit a written request to inspect and/or copy your health information. Your request may be denied in certain limited circumstances. However, if you are denied, you may ask that the denial be reviewed. We will comply with the outcome of the review. You have the right to request a correction or change to your health information if you believe it is incorrect or incomplete. Your request must be in writing and include a reason to support the request. We may deny your request if you ask us to amend information that:

a) We did not create unless the person or entity that created the information is no longer available to make the amendment.

b) Is not part of the health information that we keep.

c) You would not be permitted to inspect and copy.d) Is accurate and complete.

You have the right to request an accounting of disclosures.

This is a list of the disclosures we made of medical information about you for purposes other than treatment, payment, and health care operations. To obtain this list, you must submit your request in writing which states a time period no longer than six years and does not include dates before April 14, 2003. We may charge you for the costs of providing the list, either electronically or paper copy. However, you may choose to withdraw or modify your request at that time before any costs are incurred.

You have the right to be assured that your information will be kept confidential. You may request that we communicate with you about medical matters in a certain way or at a certain location. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

You have the right to a paper copy of this notice. If you have agreed to receive it electronically, you are still entitled to a paper copy. You may ask us to give you a copy of this notice at any time by contacting the Privacy Officer, Office of theGeneral Counsel.

Changes to This Notice We reserve the right to change this notice, and to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a summary of the current notice in the office with its effective date. You are entitled toa copy of the notice currently in effect.

Complaints you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the U.S.Department of Health and Human Services. You will not be penalized for filing a complaint.

For Further Information, Requests for further information about the information covered in this notice may be directed towards the person who gave you the notice or our Privacy Officer, The International Center For Dental Excellence, 2021 E. Commercial Blvd. #208, Ft. Lauderdale, FL 33334 or by phone at (954) 938-4599. The International Center For Dental Excellence – Dr. Yolanda Cintron D.M.D., P.A. - August 12, 2014.

I hereby acknowledge that I have received and read this Notice of Privacy Practices.
Patient Signature*

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Patient Name*

First NameLast Name
Date*

MonthDayYear
Date

Medical Records Release Form

Access and Authorization for Use and/or Disclosure of Protected Health Information

I authorize Dr. Yolanda Cintron DMD, PA to release confidential health information including but not limited to X-rays, photos, clinical findings, treatment notes , lab reports, medical histories, medications and other by email, phone, fax, and mail. I am giving permission to discuss post op instructions with your chosen responsible party that will be picking you up when you are sedated.
Physician Information
Name*

First NameMiddle NameLast Name
Address*

Street City State Zip

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Number
Email*
example@example.com
Fax Number
*

I understand that the protected health information specified below may include mental health, substance abuse (e.g., drugs, alcohol) HIV/AIDS status information, diagnostic and treatment records. I have read and understand the following statements:
*

I am the patient and/or legal guardian and I understand and agree to the provisions of this form/authorization
Name*

First NameMiddle NameLast Name
Address

Street City State Zip

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*

Area CodePhone Number
Mobile Number

Area CodePhone Number
Other Numbers
Patient’s Signature*

Clear
Patient’s Name*

First NameLast Name
Date*

MonthDayYear
Date

Photo/Video Release
Patients Name*

First NameLast Name
Date*

MonthDayYear
Date
*

I hereby authorize Dr. Yolanda Cintron DMD to publish the photograph sand videos taken of me.I hereby do not authorize Dr. Yolanda Cintron DMD to publish the photographs and videos taken of me.
I acknowledge that my photos may be used in publications, social media, and/or websites. Since my participation in publications and websites produced by Dr.Yolanda Cintron DMD is voluntary, I will receive no financial compensation.
I further agree that my participation in any publication and website produced by Dr. Yolanda Cintron confers upon me no rights of ownership whatsoever. I release Dr. Yolanda Cintron and all the employees from liability for any claim to me or any third party in connection with my participation.
Signature*

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Name*

First NameLast Name
Date*

MonthDayYear
Date
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Patient Registration

Patient Registration

Patient Information

Emergency Contact

Physician’s Information

Medical History

Notice of Privacy Practices - August 1, 2013

Physician Information

Photo/Video Release