• New Patient Form

    New Patient Form

  • PATIENT

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  • CLOSEST RELATIVE

  • DENTIST

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  • PHYSICIAN

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  • GENERAL INFORMATION

  • FINANCIAL RESPONSIBILITY

  • DENTAL INSURANCE

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  • MEDICAL INSURANCE

  • Your answers are for office records only and are confidential. A thorough medical history is essential to a complete orthodontic evaluation.

    For the following, please mark Yes, No, or Don't Know/Understand (DK/U).

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  • PATIENT HEALTH INFORMATION

  • FAMILY MEDICAL HISTORY

  • RELEASE AND WAIVER

    I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.
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  • I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.
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  • PRIVACY NOTICE

  • 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.

    Your protected health information (i.e., individually identifiable information such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed to us in one or more of the following respects:

    • To other health care providers (i.e., your general dentist oral surgeon, etc.) in connection with our rendering orthodontic treatment to you (i.e., to determine the results of cleanings, surgery, etc);
    • To third-party payers or spouses (i.e., insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) ni order to obtain payment of your account (i.e., to determine benefits, dates of payment, etc.);
    • To certifying licensing and accrediting bodies (i.e., The American Board of Orthodontics, state dental boards, etc.) in connection with obtaining certification, licensure or accreditation;
    • Internally, to all staff members who have any role in your treatment; and/or,
    • To other patients and third parties who may see or overhear incidental
      disclosures about your treatment, scheduling, etc.;
    • To your family and close friends involved in your treatment; and/or;
    • We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

    Any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke.

    Under the new privacy rules, you have the right to:

    • Request restrictions on the use and disclosure of your protected health information;
    • Request confidential communication of your protected health information;
    • Inspect and obtain copies of your protected health information by asking us;
    • Amend or Modify your protected health information in certain circumstances;
    • Receive an accounting of certain disclosures made by us of your protected
      health information; and
    • You may, without risk of retaliation, file a complaint as to any violation by us of your privacy rights with us (by submitting inquiries to our Privacy contact person at our office address) or the United States Secretary of Health and Human Services. (Which must be filed within 180 days of the violation.)


    We have the following duties under the privacy rules:

    • By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information;
    • To abide by the terms of our Privacy Notice that is currently in effect;
    • To advise you of our right to change the terms of this Privacy Notice and to make the new notice provisions effective for all protected health information maintained by us and that if we do so, we will provide you with a copy of the revised Privacy Notice.

    Please note that we are not obligated to:

    • Honor any request by you to restrict the use of your protected health information;
    • Amend your protected health information if, for example, it is accurate and
      complete; or,
    • Provide an atmosphere that is totally free of the possibility that your protected health information may be incidentally overheard by other patients and third parties.

    This privacy notice is effective as of the date of your signature. If you have any questions about the information in this notice, please ask for our Privacy contact person or direct your questions to this person at our office address. Thank You.

     

    PATIENT ACKNOWLEDGEMENT

    I hereby acknowledge that I have received and reviewed a copy of this Privacy Notice.

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  • PRIVACY CONSENT

  • This form is optional under the new patient privacy regulations recently issued by the United States Department of Health and Human Services. We have elected to use this form. Prior to commencing your orthodontic treatment, you should review, sign, and date this form.

    Your protected health information (i.e., individually identifiable information such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used in connection with your treatment, payment of your account or health care options (i.e., performance reviews, certification, accreditation, and licensure).

    You have the right to review our office's privacy notice prior to signing this Consent, a copy of which was given to you with this consent.

    You have the right to request restrictions on the use of your protected health information. However, we are not required to, and may not honor your request.
    We may amend the attached privacy notice at any time. If we do, we will provide you with a copy of the changes, and the changes may not be implemented prior to the effective date of the revised notice.

    You may revoke this consent at any time in writing. However, such revocation will not be effective to the extent that any action has been taken in reliance on this consent.

    Thank you for your cooperation. Please let us know fi you have any questions.

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  • INSURANCE CO-PAYMENT POLICY

  • As a courtesy and convenience for our patients, this office agrees to accept insurance co-payment as a means of prearrangement for payment of the orthodontic fee. We must, however, have agreement and understanding of our policy regarding the issue.

    The patient or responsible party must take responsibility for confirming eligibility for orthodontic benefits. This can be done by having the responsible party call their designated representative to determine eligibility and amounts of coverage. It would be suggested that the responsible party request a written authorization from their insurance carrier. Another means of doing this would be for our office to submit a pre-treatment authorization on the patient's behalf. This takes more time since we would be waiting on return mail.

    The responsible party may also choose to begin treatment before confirming eligibility for orthodontic benefits by signing the following statement.

  • I understand that I am responsible for the full orthodontic fee for regardless of the possible insurance benefits payable. I choose to make financial arrangements using my anticipated insurance benefits for co-payment. I further understand that in the event the insurance determines that there are reduced or no benefits, then I would need to revise my current financial arrangement so that the full payment for the treatment fee will be satisfied in the estimated active treatment time frame.

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  • INSURANCE INFORMATION

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  • PHOTO RELEASE

  • Option 1: I give my permission for Camellia Orthodontics to display my/my child's photo in the following ways:

    • Bulletin Board in Office
    • Camellia Orthodontics Facebook/Instagram Page
    • Camellia Orthodontics Website

    Option 2: I do not wish to have my/my child's photo displayed by Camellia Orthodontics in any way.

  • I understand that signing this release is optional and Camellia Orthodontics will not post my photos without my permission.

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