NP FORM WITH HIPAA

NOTICE PLEASE READ:

We recommend clicking "Save" at the end of each page so your entries are saved and you may return to the form later. A copy of your saved entries will be emailed to you and will make it easy for you to update/complete the form at your convenience. If you do not "Save" after each page and leave the form before completion, your entries will not be saved.
PATIENT'S CONTACT INFORMATION
PATIENT’S NAME *

First NameMiddle NameLast Name
PATIENT'S PREFERRED NAME *
Prefers to be called
PATIENT IDENTIFIES AS*

MALEFEMALE
PATIENT'S DATE OF BIRTH*

MonthDayYear
PATIENT'S MAILING ADDRESS*

Street Address

Address Line 2

CityState

Zip Code
Consent

I consent to recieve SMS text communication from Spillers Orthodontics for appoitment reminders, marketing messages and general two-way communication. Message frequency varies. Msg&data rates may apply. Reply HELP for support. Reply STOP to opt out. Consumer information is not shared with third parties for marketing purposes.
CELL PHONE

Area CodePhone Number
HOME PHONE

Area CodePhone Number
WORK PHONE

Area CodePhone Number
EMAIL ADDRESS*
OTHER FAMILY MEMBERS TREATED BY SPILLERS ORTHODONTICS
IS PATIENT FINANCIALLY RESPONSIBLE?*

YESNO

PRIMARY RESPONSIBLE PARTY INFORMATION
The primary responsible party is the person who is responsible for initiating the patient's care. If the patient is an adult, in most cases, they would be self responsible.
SPOUSE, PARENT, OR LEGAL GUARDIAN NAME*

First NameLast Name
RESIDENCE ADDRESS

SAME AS PATIENT
RESIDENCE ADDRESS (IF DIFFERENT FROM PATIENT)

Street Address

Address Line 2

CityState

Zip Code
YEARS AT THIS ADDRESS*
MAILING ADDRESS (IF DIFFERENT FROM RESIDENCE)

Street Address

Address Line 2

CityState

Zip Code
By submitting this form, I consent to receive SMS text messages from Spillers Orthodontics for appointment reminders, marketing messages, and general two-way communication. Msg frequency varies. Msg&data rates may apply. Reply HELP for support. Reply STOP to opt out.

Consumer information is not shared with third-parties for marketing purposes.
Consent

I consent to text communication.No, I do not consent to text communication.
CELL PHONE

Area CodePhone Number
Type a question
HOME PHONE

Area CodePhone Number
WORK PHONE

Area CodePhone Number
Email*
DATE OF BIRTH*

MonthDayYear
RELATIONSHIP TO PATIENT*
EMPLOYER*
OCCUPATION
NUMBER OF YEARS EMPLOYED
DO YOU NEED TO ADD ANOTHER RESPONSIBLE PARTY?

YESNO
SECONDARY RESPONSIBLE PARTY INFORMATION
SECONDARY SPOUSE, PARENT, OR LEGAL GUARDIAN NAME

First NameLast Name
RESIDENCE ADDRESS

SAME AS FIRST RESPONSIBLE PARTY
RESIDENCE (IF DIFFERENT)

Street Address

Address Line 2

CityState

Zip Code
YEARS AT THIS ADDRESS
MAILING ADDRESS (IF DIFFERENT FROM RESIDENCE)

Street Address

Address Line 2

CityState

Zip Code
HOME PHONE

Area CodePhone Number
WORK PHONE

Area CodePhone Number
Email
example@example.com
DATE OF BIRTH

MonthDayYear
RELATIONSHIP TO PATIENT
EMPLOYER
OCCUPATION
NUMBER OF YEARS EMPLOYED

IF NO DENTAL INSURANCE CHECK HERE

NO DENTAL INSURANCE

Insurance Information
PRIMARY POLICY HOLDER’S FIRST NAME*
PRIMARY POLICY HOLDER’S LAST NAME*
RELATIONSHIP TO PATIENT *
EX: SELF, SPOUSE, MOTHER, FATHER, LEGAL GUARDIAN
PRIMARY POLICY HOLDER'S DATE OF BIRTH*

MonthDayYear
PRIMARY POLICY HOLDER'S SS #*
PRIMARY POLICY HOLDER'S EMPLOYER*
PRIMARY INSURANCE COMPANY NAME*
GROUP NUMBER*
ID NUMBER*
PRIMARY INSURANCE COMPANY ADDRESS*

Street Address

Address Line 2

CityState

Zip Code
PRIMARY INSURANCE PHONE NUMBER*

Area CodePhone Number
WHICH IS TRUE?

PATIENT HAS DUAL DENTAL INSURANCE COVERAGEPATIENT HAS NO OTHER DENTAL INSURANCE COVERAGE

DENTAL INSURANCE INFORMATION (Continued)
SECONDARY POLICY HOLDER’S FIRST NAME*
SECONDARY POLICY HOLDER’S LAST NAME*
SECOND POLICY HOLDER'S DATE OF BIRTH*

MonthDayYear
SECONDARY POLICY HOLDER'S SS #*
SECONDARY POLICY HOLDER'S EMPLOYER*
SECONDARY INSURANCE COMPANY NAME*
GROUP NUMBER*
ID NUMBER*
SECONDARY INSURANCE MAILING ADDRESS*

Street Address

Address Line 2

CityState

Zip Code
SECONDARY INSURANCE PHONE NUMBER*

Area CodePhone Number

EMERGENCY CONTACT
NAME OF THE NEAREST RELATIVE NOT LIVING WITH PATIENT*
First and Last Name
Address*

Street Address

Address Line 2

CityState

Zip Code
RELATIONSHIP TO PATIENT*
PRIMARY PHONE*

Area CodePhone Number
OPTIONAL PHONE

Area CodePhone Number

PATIENT'S DENTAL HISTORY
REGULAR DENTIST*
APPROXIMATE DATE OF LAST DENTAL CLEANING*

MonthDayYear
LIST ANY NEEDED FILLINGS OR RESTORATIONS
IS THE PATIENT SCHEDULED FOR THE NEEDED PROCEDURES?*
IS THE PATIENT CURRENTLY IN DENTAL PAIN*
EXPLAIN DENTAL PAIN THE PATIENT IS EXPERIENCING
PATIENT HAS HAD PAST INJURIES TO FACE, MOUTH OR TEETH*
EXPLAIN PAST INJURIES TO FACE, MOUTH OR TEETH
CHECK ANY ORAL HABITS PATIENT CURRENTLY HAS OR HAS HAD IN THE PAST

THUMB/FINGER HABITNAIL BITINGPACIFIER PAST AGE 2TONGUE THRUST

ABOUT TODAY'S VISIT
IF TODAY'S VISIT REVEALS A NEED FOR TREATMENT, WHAT OPTION ARE YOU MOST INTERESTED IN?*

INVISALIGNMETAL BRACESWHATEVER DOCTOR RECOMMENDS
WHAT IS YOUR NUMBER ONE CONCERN WITH YOUR SMILE?*
WHAT MOTIVATED YOU TO COME SEE US AT THIS TIME?*
HOW DID YOU FIRST HEAR ABOUT OUR OFFICE?*
WHAT IS THE PATIENT'S PREVIOUS EXPERIENCE SEEING AN ORTHODONTIST?
PLEASE NOTE ANY MEDICAL, ALLERGY, PSYCHOLOGICAL OR SPECIAL NEEDS THAT OUR OFFICE SHOULD BE AWARE OF **NOTE IF PATIENT HAS LATEX ALLERGY**
YOUR NAME*
SIGNATURE*

Clear
Sign using cursor or finger
TODAY'S DATE

MonthDayYear

NOTICE OF INFORMATION PRACTICES

THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US. THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION IS USED AND DISCLOSED AND HOW YOU MAY ACCESS THIS INFORMATION

We are required by federal and state law to maintain the privacy of your health information. We are also required to give you this notice about our privacy practices, our legal duties and your rights concerning your health information. This notice takes effect on 4/14/03, and will remain in effect until it is replaced.

USES AND DISCLOSURES OF HEALTH INFORMATION OUR LEGAL DUTY

1. The Practice may use and disclose protected health information for treatment, payment, educational, research and healthcare operations. Treatment examples of these include, but are not limited to, referral to other providers for treatment. Payment examples include, but are not limited to, insurance companies for claims including coordination of benefits with other insurers and collection agencies. Healthcare operations examples include, but are not limited to,
internal quality control including auditing of records.

2. The Practice will not make use or disclose protected health information without the individual’s written or verbal consent or authorization. Such authorization may be revoked at any time. Revocation must be in writing. Two exceptions to this would include public health requirements and court
orders.

3. The Practice reserves the right to change the terms of this notice and make new provisions effective for all the protected health information it
maintains. The Practice will provide each patient with a copy of any revisions of this notice at the time of their next visit, or at the last known address. A copy can be obtained at the office at any time during business hours.

4. Any patient, guardian or personal representative has the right to:
a. Object to the use of their health information for directory purposes
b. Inspect and obtain copies of their orthodontic record
c. Request amendments be made to their orthodontic record
d. Request a six-year accounting of all disclosures of their orthodontic record. The history will be provided within 60 days and a reasonable charge may be assessed.
e. Request restrictions to how their information may be used or disclosed. The Practice is not required to agree to these restrictions, but if The Practice does agree, it must comply.

5. Any person or patient may file a complaint to The Practice and to the Secretary of Health and Human Services if they believe their privacy rights have been violated. To file a complaint with The Practice, please contact the Privacy Officer at the regular office address or phone number. All complaints will be addressed and the results will be reported to the privacy officer. It is the policy of The Practice that no retaliatory action will be made against any individual who submits a complaint of suspected or actual non-compliance of the privacy standards.

6. The practice will consider the implied consent for release of information if a patient is accompanied by another party.

CONSENT TO USE AND DISCLOSURE

I, {yourName} have had the opportunity to read the HIPAA Notice and consent to the use and disclosure of my protected information to carry out treatment, payment activities and health care operations.

Name of Patient {patientsName} Date {todaysDate}
I have had the opportunity to read the HIPAA Notice and consent to the use and disclosure of my protected information to carry out treatment, payment activities and health care operations.*

I agreeI disagree
Signature of Patient, Parent or Legal Guardian*

Clear
Sign using cursor or finger
Should be Empty:

NOTICE PLEASE READ:

PATIENT'S CONTACT INFORMATION

PRIMARY RESPONSIBLE PARTY INFORMATION

SECONDARY RESPONSIBLE PARTY INFORMATION

Insurance Information

DENTAL INSURANCE INFORMATION (Continued)

EMERGENCY CONTACT

PATIENT'S MEDICAL HISTORY

PATIENT'S DENTAL HISTORY

ABOUT TODAY'S VISIT