Child New Patient Form

Child New Patient Form
Today's Date*

MonthDayYear
Name*

First NameLast Name
Nick Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
School
Hobbies/Interests
Father's Name
Father's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Home Phone Number
Please enter a valid phone number.
Father's Cell Phone Number
Please enter a valid phone number.
Father's Employer*
Father's Work Number
Please enter a valid phone number.
Father's Insurance
Mother's Name*
Mother's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Home Phone Number
Please enter a valid phone number.
Mother's Cell Phone Number
Please enter a valid phone number.
Mother's Employer
Mother's Work Number
Please enter a valid phone number.
Mother's Insurance
Person Responsible for Account*
Email Address*
Insurance Subscriber's DOB*

MonthDayYear
Dental History
Dentist Name*
Date of last dental exam/cleaning?*
To your knowledge do you have any outstanding dental work that needs to be completed?*

YesNo
If yes, please explain:
Do you give permission for our office to share images and consult/treatment notes with their dentist?*

YesNo
What concern brings you to our office?*
Habits

ThumbsuckingMouth BreathingGrinding
Has there been injury to the face, head or neck?*

YesNo
If yes, please explain:

Acknowledgement of Receipt of Statement of Privacy Policy
I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Nelson R. Diers, D.D.S. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

Nelson R. Diers, D.D.S. reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed to me.
ADDITIONAL DISCLOSURE AUTHORITY

In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below.
Any member of my immediate family*

YesNo
Spouse only*

YesNo
Other (please specify)*

YesNo
Other*
Name of Patient or Personal Representative*

First NameLast Name
Signature of Patient or Personal Representative*
Type full name to sign
Date*

MonthDayYear
Description of Personal Representative's Authority

Statement of Privacy Practices

Our office is dedicated to protect the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee to ensure that your health information is never compromised is a principal concept of our practice. We may, from time to time, amend our privacy policies and practices but will always inform you of any changes that might affect your rights.

Protecting Your Personal Healthcare Information

We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and Account-ability Act and the state of Ohio. This includes issues relating to your treatment, payment, and our health care operations. Your personal health information will never be otherwise given to anyone - even family members - without your written consent. You, of course, may give written authorization for us to disclose your information to anyone you choose, for any purpose.

Our office and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentially of your records is always protected. Our privacy policy and practices apply to all former, current, and future patients, so you can be confident that your protected health information will never be improperly disclosed or released.

Collecting Protected Health Information

We will only request personal information needed to provide our standard of quality health care, implement payment activities, conduct normal health practice operations, and comply with the law. This may include your name, address, telephone number(s), Social Security Number, employment data, medical history, health records, etc. While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law.

Disclosure of Your Protected Health Information

As stated above, we may disclose information as required by law. We are obligated to provide information to law enforce-ment and governmental officials under certain circumstances. We will not use your information for marketing purposes without your written consent.

We may use and/or disclose your health information to communicate reminders about your appointments including voice-mail messages, answering machines, and postcards.

Patient Rights

You have a right to request copies of your healthcare information; to request copies in a variety of formats; and to request a list of instances in which we, or our business associates, have disclosed your protected information for uses other than stat-ed above. All such requests must be in writing. We may charge for your copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately. You can also notify the U.S. Department of Health and Human Services.

We thank you for being a patient at our office. Please let us know if you have any questions concerning your privacy rights and the protection of your personal health information.
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