• Gartner Periodontal Care, Inc.

  • Welcome

    Thank you for selecting our periodontal healthcare team!
    We will strive to provide you with the best possible dental care.

    To help us meet your dental healthcare needs, please fill out this form completely.
    If you have any questions or need assistance, please ask us - we will be happy to help.

  • Patient Information(Confidential)

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  • Responsible Party

  • Insurance Information

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  • Patient Medical History

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  • 8. Women Only:

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  • Patient Medical History

  • 6. Have you ever experienced any of the following problems in your jaw?

  • Authorization and Release

  • I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination renduced to me or my child during the period of such dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may less than the actual  bill for service. I agree to be responsible for payment of all services on my behalf or my dependents.

    I realize that failure to keep this account current may result in collection activity and agree to pay necessary costs and attorney fees incurred in attempting to collect on this account.

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  • MEDICAL RISKS AND PERIODONTAL DISEASE

  • 4 WAYS PERIODONTAL INFECTION CAUSES MEDICAL PROBLEMS

    1. BLOOD STREAM - Chewing Injects Infectious Bacteria into Your Blood Stream.
    Penodontal bacteria in the blood stream increased 4 times (24%) in those who chewed just 50 times.

    2. BREATHING - Periodontal Bacteria Are Breathed Into Your Lungs.
    Periodontal bactctia can be breathed into the lungs and increase the incidence of lung disease.

    3. IMMUNE SYSTEM - Periodontal Infection Can Lower Your Immune System.
    A study has found that health care costs were 21% higher for those patients with severe periodontal disease.

    4. TRANSMISSION - Periodontal Infection Is Transmitted to Your Spouse & Children.
    DNA tests show that periodontal infection is transmitted directly from spouse to spouse and parent to child.

  • RESEARCH FINDINGS

  • ALZHEIMER'S -- DETERMINING FACTOR
    Gum disease early in life, less education, and a history of stroke are more important than genes in detrmining who develops dementia, concluded a study of 100 demenna patients with healthy identical twins.

    BLOOD CANCERS - 30% MORE RISK
    A demographic study of nearly 50,000 men showed that those with periodontal disease had a 30% higher risk of blood cancers, including: leukemia multiple myeloma and non-IIodgkin lymphoma

    DIABETES - INCREASES SEVERITY
    Periodontal disease affects blood sugar control, lengthens the duration of diabetes symptoms, and speeds the transition from pre-diabetes to diabetes.

    DIABETES - 2.8 - 3.4 TIMES MORE RISK
    Diabetic patients are 2.8 to 3.4 times more likely to have periodontal disease.

    HEART ATTACK - 2.7 TIMES MORE RISK
    Demographic studies of 1,372 subjects showed those with periodontal disease were 2.7 times more likely to have heart attack.

    HEART DISEASE - 40-72% MORE RISK
    Demographic studies of 10,909 subjects showed a 40% to 72% increased risk of heart disease.

    KIDNEY CANCER - 49% MORE RISK
    A demographic study of nearly 50,000 men showed that those with periodontal disease had a 49% higher risk of kidney cancer.

    LUNG CANCER - 36% MORE RISK
    A demographic study of nearly 50,000 men showed that those with periodontal disease had a 36% higher risk of lung cancer.

    LUNG DISEASE - 1.5 TIMES MORE RISK
    In a demographic study of 13,792 individuals, those with periodontal disease had a 1.5 times greater risk of getting chronic obstructive pulmonary disease

    OBESITY 76% HIGHER IN YOUNG ADULTS
    In a study of 13,645 young adults (18-34) who had periodontal disease, 76% were more likely to be obese.

    OSTEOPOROSIS - TREATMENT LINK
    Research has shown that treating ostetprosis can lower the seventy of periodontal disease.

    PANCREATIC CANCER - 63% MORE RISK
    In a study of 51,529 males, it was found that men with periodontal disease had a 63% to 126% higher risk of pancreatic cancer

    PREMATURE CHILDBIRTH - 79% HIGHER
    Premature low birth-weight childbirth greatly increases complications. Women with untreated periodontal disease have a 79% higher chance of premature childbirth. Treatment gives an 84% reduction in premature births.

    STROKE - BACTERIA IN BLOOD CLOTS
    Periodontal bacteria have been found in blood clots and those with periodontal disease have a higher risk of strokes

    TONGUE CANCER - 5 TIMES MORE RISK
    Men With advanced periodontal disease have more than times the risk of tongue cancer.

  • Patient Financial Responsibility Agreement

  • We are honored you have chosen us for our dental care. In order to keep a completely professional and up front business relationship with our patients, we ask that you read and state that you understand our payment policy and our insurance policy. If you do not have dental issuance please skip down to the bottom of the page.

    Payment Options

    1. Cash- Includes money orders and personal checks. If the total fee for your services is $500 or more we offer a 5% discount if you pay in full on the originating date of service.

    2. Visa/MasterCard/Discover

    3. Care Credit — the monthly payment plan is offered as a separate line of credit to cover your healthcare needs. With Care Credit:

    • Approval only takes a few minutes
    • We offer No Interest Option
    • We also offer low interest extended payment plan options, for more time to pay off larger balances.

    I understand that my insurance policy is a contract between my insurance company and myself. The contract is not between Gartner Periodontal Care and my insurance company. I know that I am fully responsible for all charges resulting from services rendered to me, including the balance remaining after payment of possible insurance benefits.

    In instances where pre-determinations are approved, you may pay your co-payment and we will file for the remaining balance. However, if payment from your insurance company is not received within 30 days we will notify you of the balance due and your payment is expected in full at that time.

    If no previous arrangements have been made, all balances overdue by 60 days will have a 1.50% assessed with a minimum charge of $2.00.

    We will bill your insurance for you as courtesy, but please understand that your insurance contract will always use an “allowable amount” payment for each procedure provided. This “allowable” is determined by the limitations of the contract that your employer or the individual has purchased from the company and does not always equal the doctor's submitted fee. You will be responsible to the doctor for payment of your yearly deductible, the patient portion and any other remaining portion for the doctor's bill that is not covered by your insurance; we will collect this at the time of service. Any unpaid balance by the insurance company is your responsibility.

    I understand that should my account become delinquent, I will be legally responsible for all cost involved with the collection of this account including all court cost, reasonable attorney fees and all other related costs.

    Please understand that there might be a fee for any appointments cancelled without a twenty four hour notice.

    Please sign and date that you understand and agree to our policy. Thank you.

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  • NOTICE OF PRIVACY PRACTICES

    Effective Date: 6-25-2025
  • 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. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.

    CONTACT INFORMATION

    For more information but our privacypractices, to discuss questions or concerns, or to get additional copies of this notice, please contact our Privacy Officer.

  • OUR LEGAL DUTY

    We are required by law to protect the privacy of your protected health information ("medical information"). We are also required to send you this notice about our privacy practices, our legal duties, and your rights conceming your medical information.

    We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect on the date set forth at the top of this page, and will remain in effect unless we replace it.

    We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make any change in our privacy practices and the new terms of our notice applicable to all medical information we maintain, including medical information we created or received before we made the change.

    We may amend the terms of this notice at any time. If we make a material change to our policy  ractices, we will provide to you the revised notice. Any revised notice will be effective for all health information that we maintain. The effective date of a revised notice will be noted. A copy of the current notice in effect will be available in our facility and on our website if applicable. You may request a copy of the current notice at any time.

    We collect and maintain oral, written and electronic information to administer our business and to provide products, services and information of importance to our patients. We maintain physical, electronic and procedural security safeguards in the handling and maintenance of our patient medical information, in accordance with applicable state and federal standards, to protect against risks such as loss, destruction or misuse.

    USES AND DISCLOSURES OF YOUR MEDICAL INFORMATION 

    Treatment: We may disclose your medical information, without your prior approval, to another dentist, a physician or other health care provider working in our facility or otherwise providing you teatment for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, your health information may be disclosed to an oral surgeon to determine whether surgical intervention is needed.

    Payment: We provide dental services. Your medical information may be used to seek payment from your insurance plan. For example, your insurance plan may request and receive information on dates bat you received services at our facility in order to allow your employer to verify and process your insurance claim.

    Health Care Operations: We may use and disclose your medical information, without your prior approval, for health care operations. Health care operations include:

    • healthcare quality assessment and improvement activities;
    • reviewing and evaluating dental care provider performance, qualifications and competence, health care training programs, provider accreditation, certification. licensing and credentialing activities;
    • conducting or arranging for medical reviews, audits, and legal services, including fraud and abuse detection and prevention; and
    • business planning, development, management, and general administration, including customer service, complaint resolutions and billing, de-identifying medical information, and creating limited data sets for health care operations, public heart activites, and research.

    We may disclose your medical information to another dental or medical provider or to your health plan subject to federal privacy protection laws, as long as the provider or plan has or had a relationship with you and the medical information is for that provider's or plan's health care quality assessment and improvement activities, competence and qualification evaluation and review activities, or fraud and abuse detection and prevention.

    Your Authorization: You (or your legal personal representative) may give us written authorization to use your medical information or to disclose it to anyone for any purpose. Once give us authorization to release your medical information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization at any time in writng, except if we have already acted based on your authorization. Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect unless you give us a written authorization. We will not use or disclose your medical informaton for any purpose other than those described in this notice. We will obtain your authorization prior to using your medical information for marketing, fundraising purposes or for commercial use. Once authorized, you may opt out of any of these communications.

    Family, Friends, and Others Involved In Your Care or Payment for Care: We may disclose your medical information to a family member, friend or any other person you involve in your care or payment for your health care. We will disclose only the medical information that is relevant to the person's involvement. 

    We may use or disclose your name, location, and general condition to notify, or to assist an appropriate public or private agency to locate and notify, a person responsible for your care in appropriate situations, such as a medical emergency or during disaster relief efforts.

    We will provide you with an opportunity to object to these disclosures, unless you are not present or are incapacitated or it is an emergency or disaster relief situation. In those situations, we will use our professional judgment to determine whether disclosing your medical information is in your best interest under the circumstances.

    Health-Related Products and Services: We may use your medical information to communicate with you about health-related products, benefits, services, payment for those products and services, and treatment atternatives.

    Reminders: We may use or disclose medical information to send you reminders about your dental care, such as appointment reminders.

    Plan Sponsors: If your dental insurance coverage is through an employer's sponsored group dental plan, we may share summary health information with the plan sponsors.

  • Public Health and Benefit Activities: We may use and disclose your medical information, without your permission, when required by law, and when authorized by law for the following kinds of public health and benefit activities:

    • for public health, including to report disease and vital statistics, child abuse.
      and adult abuse, neglect or violence;
    • to avert a serious and imminent threat to health or safety;
    • for heatth care oversight, such as actvities of state insurance commissioners, licensing and peer review authorities, and fraud prevention agencies;
    • for research:
    • in response to court and administrative orders and other lawful process;
    • to law enforcement officials with regard to crime victims ard criminal activities:
    • to coroners, medical examiners, funeral directors, and organ procurement
      organizations;
    • to the military, to federal officials for lawful intelligence, counterintelligence, and national security activities, and to correctional and law enforcement regarding persons in lawful custody; and
    • as authorized by state worker's compensation laws.

    If a use or disclosure of health information described above in this notice is prohibited or materially limited by offer laws that apply to us, it is our intent to meet the requirements of the more stringent law.

    Business Associates: We may disclose your medical information to our business associates that perform functions on our behalf or provide us with services if the informations is necessary for such functions or services. Our business associates are required, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than
    as specified in our contract.

    Data Breach Notification Purposes: We may use your contact information to provide legally-required notices or unauthorized acquisition, access, or disclosure of your health information.

    Additional Restrictions on use and Disclosure: Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential about you. "Highly confidential information" may include confidential information under Federal laws governing alcohol and drug abuse information and genetic infomation as well as state laws that often protect the following types of informaton.
    1. HIV/AIDS;
    2. Mental health;
    3. Genetic tests;
    4. Alcohol and drug abuse:
    5. Sexually transmitted diseases and reproductive health information; and
    6. Child or adult abuse or neglect, including sexual assault

    YOUR RIGHTS

    Access: You have the right to examine and to receive a copy of your medical information, with limited exceptions. We will use the format you request unless we cannot practicably do so. You should submit your request in writing to our Privacy Officer.

    We may charge you reasonable, cost-based fees for a copy of your medical information, for mailing the copy to you, and for preparing any summary or explanation of your medical information you request. Contact our Privacy Officer for information about our fees.

    Disclosure Accounting: You have the right to a list of instances in which we disclose your medical information for purposes other than treatment, payment, health care operations, as authorized by you, and for certain other activities.

    You should submit your request to our Privacy Officer. We will provide you with information about each accountable disclosure that we made during tle period for which you request the accounting, except we are not obligated to account for a disclosure that occurred more man 6 years before the date of your request

    Amendment: You have the right to request that we amend your medical infomation. You should submit your request in writing to our Privacy Officer. 

    We may deny your request only for certain reasons. If we deny your request, we will provide a written explanation. If we deny your request, you may have a statement of your added to your medical information. If we accept your request, we will make pur amendment part of your medical information and use reasonable efforts to inform others of the amendment we know may have and rely on the unamended information to your detriment, well as persons you want to receive the amendment.

    Restriction: You have the right to request that we restrict our use or disclosure of your medical information for treatment, payment or health care operations, or with family, friends or others you identify. Except in limited circumstances, we are not required to agree to your request. But if we do agree, we will abide by our agreement, except in a medical emergency or as required or authorized by law. You should submit your request to our Privacy Offcer. Except as otherwise required by law, we must agree to a restriction request if:

    1. except as otherwise required by law, the disclosure is to a health plan for purposes of carrying out payment or health care operations (and not for purposes of carrying out treatment); and
    2. the medical information pertains solely to a health care item or service which the healthcare provider involved has been paid out pocket in full by the patient.

    Confidential Communication: You have the right to request that we communicate with you about your medical information in confidence by means or to locations that you specify. You should submit your request in writing to our Privacy Officer.

    Breach Notification: You have the right to receive notice of a breach of your unsecured medical information. Breach may be delayed or not provided if so required by a law enforcement offical. You may request that notice provided by electronic mail. If you are deceased and there is a breach of your medical information, the notice will be provided to your next of kin or personal representatives if we know the identity and address of such individual(s).

    Electronic Notice: If you receive this notice on our web site or by electronic mail (e-mail), you are entitled to receive this notice in written form. Please contact our Privacy Officer to obtain this notice in written form.

    COMPLAINTS

    If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your medical information, about amending your medical  information, about restricting our use or disclosure of your medical information, or about how we communicate with you about your medical information (including a breach notice communication), you may contact to our Privacy Officer.

    You also may submit a written complaint to the Office for Civil Rights of the United States Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, Washington, D.C. 20201. You may contact the Office for Civil Rights' Hotline at 1-800-368-1019.

    We support your right to the privacy of your medical infomation. We will not retaliate in any way if you choose to file a complaint with us or with the U.S Department of Health and Human Services.

  • ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

    **You May Refuse to Sign This Acknowledgement**
  • I,        , have received a copy of this office's Notice of Privacy Practices.

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  • Referring Form

  • 10526 W. Cermak #201, Westchester, IL 60154  Phone 708-681-5154  Fax 708-681-5315
    www.GartnerPerio.com  gumdoc@GartnerPerio.com

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  • Privacy of your Medical Information

  • WE'RE CONCERNED ABOUT YOU

    We understand that you are unique and have unique concerns. You may also have special needs for treatment given your medical history. So that we can provide you with the best possible care, please check off the statements that apply to you, Sincerely, Bruce A. Gartner, DDS

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