EP Family Orthodontics - Patient Intake (Complete)

Patient Information
Patient Name*

First NameLast Name
Address*

Street Address

Apt / Suite

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Phone Type*

HomeCellWorkOther
Date of Birth*

MonthDayYear
Date
Social Security Number*
If you wish to not provide online, please enter 999-99-9999
If the patient is a minor, give parent's or legal guardian's name

First NameLast Name

Insurance Information
Do you have insurance you'd like to use?*

YesNo
Primary Insurance Policy Holder Name*

First NameLast Name
Policy Holder Date of Birth*

MonthDayYear
Date
Policy Holder Social Security Number*
If you wish to not provide online, please enter 999-99-9999
Name of Primary Insurance Company*
Primary Insurance Group Number*
Primary Insurance Membership ID Number*
Primary Insurance Company Address*

Street Address

Suite #

CityState

Zip Code
Primary Insurance Phone Number*
Please enter a valid phone number.
Do you have secondary insurance as well?*

YesNo

Secondary Insurance
Secondary Insurance Policy Holder Name*

First NameLast Name
Policy Holder Date of Birth*

MonthDayYear
Date
Policy Holder Social Security Number*
If you wish to not provide online, please enter 999-99-9999
Name of Secondary Insurance Company*
Secondary Insurance Group Number*
Secondary Membership ID Number*
Secondary Insurance Company Address*

Street Address

Suite #

CityState

Zip Code
Secondary Insurance Phone Number*
Please enter a valid phone number.

Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Relationship to Patient*
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Phone Type*

HomeCellWorkOther

Wrapping Up
How did you hear about us?*

Google/Web searchReferralFacebookInstagramWalk-in
Whom may we thank for referring you?*

First NameLast Name
The information that I have given is correct, to the best of my knowledge. I understand that it is my responsibility to inform this office of any changes in my / my child's medical or dental status.

Benefits of Orthodontics: Aesthetics, Health, and Function. Orthodontics is a service that provides and improvement in the appearance of the teeth, in the general foundation of the teeth, and in general dental health. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases.

I request that the doctors and staff of El Paso Family Orthodontics transfer manually and/or electronically all information related to payment for and treatment of my / my child's orthodontic case to other dentists, physicians, insurance companies, Medicaid programs, and support communities (i.e., custom appliance labs, computerized study model companies). Such reports may include, but are not limited to, medical, dental, and orthodontic care and treatment; illness or injury; dental and medical history; consultation; prescriptions; X-rays; photographs; models; and all copies of financial payment, dental, and medical records.

I authorize Dr. Michelle Espina to perform a complete orthodontic evaluation.
Patient Name / Legal Guardian (if patient is a minor)*

First NameLast Name
Signature of Patient / Legal Guardian (if patient is a minor)*

Clear
Signature Date*

MonthDayYear
Date

Notice of Privacy Practices
This notice describes how your medical information may be used and disclosed, and how you can receive this information. Please review it carefully.
Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and our responsibilities to help you.

Get an electronic or paper copy of your medical record.
- You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
- We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record.
- You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
- We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential information.
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- We will say “yes” to all reasonable requests.
Ask us to limit what we use or share.
- You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information.
- You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice.
- You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you.
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated.
- You can complain if you feel we have violated your rights by contacting us using the information at the top of this page.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Ave, S.W., Washington, DC 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints
- We will not retaliate against you for filing a complaint.
Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:
- Share information with your family, close friends, or others involved in your care
- Share information in a disaster relief situation
- Include your information in a hospital directory
- Contact you for fundraising efforts
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases, we never share your information unless you give us written permission:
- Marketing purposes
- Sale of your information
- Most sharing of psychotherapy notes
In the case of fundraising:
- We may contact you for fundraising efforts, but you can tell us not to contact you again.
Our Uses and Disclosures

How do we typically use or share your health information? We typically use or share your health information in the following ways:

Treat you.

We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization.

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services.

We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more info see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues.

We can share health information about you for certain situations such as preventing disease, helping with product recalls, reporting adverse reactions to medications, reporting suspected abuse, neglect, or domestic violence, and/or preventing or reducing a serious threat to anyone’s health or safety.

Do research.

We can use or share your information for health research.

Comply with the law.

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests.

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director.

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests.

We can use or share health information about you:
- For workers’ compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions.

We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Our Responsibilities
- We are required by federal and state law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your Protected Health Information (PHI) electronically or otherwise other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
I acknowledge receiving the practice's "Notice of Privacy Practices" dates 3/5/2021.
Patient Name*

First NameLast Name
Signature of Patient / Legal Guardian (if patient is a minor)*

Clear
Signature Date*

MonthDayYear
Date

Authorization for Use or Disclosure of Protected Health Information
I hereby voluntarily authorize the disclosure of information from my health record. I understand that I may revoke this authorization at any time in writing and submitted to the Covered Entity above, except to the extent that action has been taken in reliance on this authorization.
Patient Name*

First NameLast Name
Signature of Patient / Legal Guardian (if patient is a minor)*

Clear
Signature Date*

MonthDayYear
Date
The information from my health record is to be disclosed by the Covered Entity above and provided to the following:
Please list the name of person(s)/organization(s) as well as their street address.
Please share entire health record*

YesNo
If no, please share information only related to:
Please share information contained in the following range:*
Please specify a date range that is acceptable to share

Photo Shoot Model Release Form
In consideration of my engagement as a model, upon the terms herewith stated, I hereby give to El Paso Family Orthodontics*, legal representatives and assigns, those for whom El Paso Family Orthodontics is acting, and those acting with his/her authority and permission:

A) The unrestricted right and permission to copyright and use, re-use, publish, and republish photographic portraits or pictures of me or in which I may be included intact or in part, composite or distorted in character or form, without restriction as to changes or transformations in conjunction with my own or a fictitious name, or reproduction hereof in color or otherwise, made through any and all media now or hereafter known for illustration, art, promotion, advertising, trade, or any other purpose whatsoever.

B) I also permit the use of any printed material in connection therewith.

C) I hereby relinquish any right that I may have to examine or approve the completed product or products or the advertising copy or printed matter that may be used in conjunction there-with or the use to which it may be applied.

D) I hereby release, discharge and agree to save harmless El Paso Family Orthodontics, legal representatives or assigns, and all persons functioning under his/her permission or authority, or those for whom he/she is functioning, from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form whether intentional or otherwise, that may occur or be produced in the taking of said picture or in any subsequent processing thereof, as well as any publication thereof, including without limitation any claims for libel or invasion of privacy.

E) I hereby affirm that I am over the age of majority and have the right to contract in my own name or contract for the minor listed below who will appear in the photo shoot. I have read the above authorization, release and agreement, prior to its execution; I fully understand the contents thereof. This agreement shall be binding upon me and my heirs, legal representatives and assigns.
Model's Name*

First NameLast Name
Model's Date of Birth*

MonthDayYear
Date
Signature of Model / Legal Guardian (if patient is a minor)*

Clear
Signature Date*

MonthDayYear
Date
Should be Empty:

	Yes	No
Are you presently in any dental pain?
Have you ever experienced any unfavorable reaction to dentistry?
Have you lost or chipped any teeth?
Have there been any injuries to your face, mouth or teeth?
Is any part of your mouth sensitive to temperature?
Is any part of your mouth sensitive to pressure?
Do your gums bleed when you brush?
Do you have any type of thumb or tongue habit?
Are you a mouth breather?
Have you ever seen an orthodontist?
Has anyone in your family received orthodontic treatment?
Do your teeth or jaws ever feel uncomfortable when you wake in the morning?
Are you aware of your jaw clicking or popping?
Are you aware of clenching your teeth during the day?
Have you ever been told that you grind your teeth?
Do you have "tension" headaches?
Have you ever experienced chronic ringing in your ears?
Are you aware that some appointments will be during school/work hours?
Female patients only: Are you pregnant?
Female patients only: Has menstruation started?

Patient Information

Responsible Party Information

Insurance Information

Secondary Insurance

Emergency Contact Information

Medical Information

Dental History

Wrapping Up

Notice of Privacy Practices

Your Rights

Your Choices

Our Uses and Disclosures

Our Responsibilities

Changes to the Terms of this Notice

Authorization for Use or Disclosure of Protected Health Information

Photo Shoot Model Release Form