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120 1ST AVE SW LARGO, FL 33770 (727) 518-8349 PATIENT HEALTH HISTORY (ADULT) Date: Sex: Legal Name: Last Name First Name Male Middle Initial Birth Date: Address: Social Security Number: Primary Phone: City State Alternate Phone: Minor Single Patient Employer: Married Divorced Zip Email: Widowed Separated Occupation: Spouse's Name: SS Number: Spouse's Employer: Birth Date: Primary Phone: Occupation: How did you hear about our office?: IN CASE OF EMERGENCY CONTACT Relationship: Alternate: Contact Name: Primary Phone: Who is responsible for this account?: Insurance Company: Member ID: Subscriber: Group ID: DENTAL HISTORY Reason for today's visit? Former Dentist: Last Exam: X-Rays: Please mark to indicate if you have had any of the following: Bad Breath Bleeding Gums Blister on lips or mouth Burning sensation on tongue Chew on one side of mouth Cigarette, pipe, or cigar smoking Clicking or popping jaw Dry mouth Fingernail biting Food collection between teeth Foreign objects Grinding teeth Gums swollen or tender Jaw pain or tiredness Lip or cheek biting Loose teeth or broken fillings Mouth breathing Mouth pain, brushing Orthodontic treatment Pain around ear Periodontal treatment Sensitivity to cold Sensitivity to heat Sensitivity to sweets Sensitity when biting Sores or growths in your mouth How often do you floss? How often do you brush? OVER Female HEALTH HISTORY Are you under a physician's care now? Primary Care Doctor Have you ever been hospitalized or had major operation?(List) Have you ever had serious neck or head injury? Do you use controlled substances? Are you taking or ever taken PHEN-FEN or REDUX? Have you ever taken FOSAMAX, BONIVA, ACTONEL, or bisphonates? Special Diet? Do you use tobacco? Medications, Pills, or Drugs Please list: Women: Are you….. Pregnant/Trying Nursing Taking oral contraceptives ALLERGIES Aspirin Penicillin Codeine Acrylic Sulfa Drugs Metal Latex Other? Do you have or have you had any of the following? AIDS/HIV Positive Cortisone Medicine Hepatitis A Rheumatic Fever Alzheimer's Disease Diabetes Hepatitis B or C Rheumatism Anaphylaxis Drug Addiction Herpes Scarlet Fever Anemia Easily Winded High Blood Pressure Shingles Angina Emphysema High Cholesterol Sickle Cell Disease Arthritis/Gout Epilepsy or Seizures Hives or Rash Sinus Trouble Artificial Heart Valve Excessive Bleeding Hypoglycemia Spinal Bifida Artificial Joint Excessive Thirst Irregular Heartbeat Stomach/Intestinal Disease Asthma Fainting Spells/Dizziness Kidney Problems Stroke Blood Disease Frequent Cough Leukemia Swelling of Limbs Blood Transfusion Frequent Diarrhea Liver Disease Thyroid Disease Breathing Problems Genital Herpes Low Blood Pressure Tonsillitis Bruise Easily Glaucoma Mitral Valve Prolapse Tuberculosis Cancer Hay Fever Osteoporosis Tumors or Growths Chemotherapy Heart Attack/Failure Pain in Jaw Joints Ulcers Chest Pains Heart Murmur Parathyroid Disease Venereal Disease Cold Sores/Fever Blister Heart Pacemaker Psychiatric Care Yellow Jaundice Congenital Heart Disorder Heart Trouble/Disease Radiation Treatments Contact Lenses Convulsions Hemophilia Recent Weight Loss Other: Hemophilia Renal Dialysis x Patient Signature Date Local Anesthetics Pinellas Family Dental 120 1st Ave SW Largo, FL 33770 (727) 518-8349 Phone (727) 518-8339 Fax www.dentalflorida.com Informed Consent For General Dental Procedures You the patient have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment. Do not consent to treatment unless and until you discuss potential benefits, risks, and complications with your dentist and all your questions are answered. By consenting to treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the probability of occurrence. As with all surgery, there are commonly known risks and potential complications associated with dental treatment. No one can guarantee the success of the recommended treatment, or that you will not experience a complication or less than optimal result. Even though many of these complications are rare, they can and do occur occasionally. Some of the more commonly know risks and complications of treatment include, but are not limited to the following: 1. Pain, swelling, and discomfort after treatment. 2. Infections in need of medication, follow-up procedures, or other treatment. 3. Temporary or on rare occasion permanent numbness, pain, tingling, or altered sensation of the lip, face, chin, gums, and tongue along with possible loss of taste. 4. Damage to the adjacent teeth, restorations, or gums. 5. Possible deterioration of your condition which may result in tooth loss. 6. The need for replacement of restorations, implants, or other appliances in the future. 7. An altered bite in need of adjustment. 8. Possible injury to the jaw joint and related structures requiring follow-up care and treatment, or consultation by a dental specialist. 9. A root tip, bone fragment, or piece of dental instrument may be left in your body, and may have to be removed at a later time if symptoms develop. 10. Jaw Fracture 11. If upper teeth are treated, there is a chance of sinus infection or opening between the mouth and sinus cavity resulting in infection or the need for further treatment. 12. Allergic reaction to anesthetic or medication. 13. Need to follow-up treatment, including surgery It is very important that you provide your dentist with accurate information before, during, and after treatment. It is equally important that you follow your dentist’s advice and recommendations regarding medication, pre and post treatment instructions, referrals to other dentist or specialists, and return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome. Pinellas Family Dental 120 1st Ave SW Largo, FL 33770 (727) 518-8349 Phone (727) 518-8339 Fax www.dentalflorida.com Certain heart conditions may create a risk of serious or fatal complications. If you (or a minor patient) have a heart condition or heart murmur, advise your dentist immediately so he/she can consult your physician if necessary. The patient is a part of the treatment team. In addition to complying with the instructions given to you by this office, it is important to report any problems or complications you experience so they can be addressed by your dentist. If you are a woman on oral birth control medication, you must consider the fact that antibiotics might make oral birth control less effective. Please consult with your physician before relying on oral birth control medication if you dentist prescribes, or if you are taking antibiotics. If you are contemplating having a tooth removed (extraction) or gum and bone surgery (periodontal surgery) and are taking orally or IV or have taken orally or IV Fosamax (Alendronate) or Actonel (Risedronate) or Boniva (Ibandronate) or Bonefos (Clodronate) or Aredia (Pamidronate) or Zometa (Zoledronic acid). Then this area may not heal ever, resulting in non-healing exposed bone (osteonecrosis or recalcitrant non-healing bone or osteochemonecrosis or ONJ). Please consult your physicians etc. prior to asking your dentist to remove (extract) a tooth and or do gum and bone surgery (periodontal surgery). In an effort to control the increasing costs of dental care, any claims or disputes against this office shall be resolved by “binding arbitration.” By signing this agreement, the patient agrees with the office of Pinellas Family Dental, that any dispute relating to dental or medical care services rendered for any condition, including any services rendered prior to the date this agreement was signed, and any dispute arising out of the diagnosis, treatment, or care of the patient, including the scope of this arbitration clause and the arbitrability of any claim or dispute, against whenever made, (including to the full extent permitted by applicable law third parties who are not signatories to this agreement [including associates]) shall be resolved by binding arbitration by the National Arbitration Forum, under the Code of Procedure then in effect. The patient understands that the result of this arbitration agreement is that claims, including malpractice claims he/she may have against the doctor, cannot be brought as a lawsuit in court before a judge or jury, and agrees that all such claims will be resolved as described in this section. This form is intended to provide you with any overview of potential risks and complications. Do not sign this form or agree to treatment until you have read, understood, and accepted each paragraph stated above. Please discuss the potential benefits, risks, and complications of recommended treatment with your dentist. Be certain all of your concerns have been addressed to your satisfaction by your dentist before commencing treatment. _________________________________ _________________________________ Patient Witness Date ________________________________ Print Patient Name Date _________________________________ Parent/ Legal Guardian Date Pinellas Family Dental 120 1st Ave SW Largo, FL 33770 (727) 518-8349 Phone (727) 518-8339 Fax www.dentalflorida.com Notice of Privacy Practices THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY OUR PRVACY PRACTICES COMPLY WITH OMNIBUS 2013 – EFFECTIVE 09/23/2013 Pinellas Family Dental is required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 09/23/2013, and will remain in effect until 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, and to make new Notice provisions effective for all protected health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new Notice upon request. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice. HOW WE MAY USE AND DICLOSE HEALTH INFORMATION ABOUT YOU We may use and disclose your health information for different purposes, including treatment, payment, and health care operations. For each of these categories, we have provided a description and an example. Some information, such as HIV-related information, genetic information, alcohol and/or substance abuse records, and mental health records may be entitled to special confidentiality protections under applicable state or federal law. We will abide by these special protections as they pertain to applicable cases involving these types of records. Treatment. We may use and disclose your health information for your treatment. For example, we may disclose your health information to a specialist providing treatment to you. Payment. We may use and disclose your health information to obtain reimbursement for the treatment and services you receive from us or another entity involved with your care. Payment activities include billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your dental health plan containing certain health information. Healthcare Operations. We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, conducting training programs, and licensing activities. Individuals Involved in Your Care or Payment for Your Care. We may disclose your health information to your family or friends or any other individual identified by you when they are involved in your care or in the payment for your care. Additionally, we may disclose information about you to a patient representative. If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information. Disaster Relief. We may use or disclose your health information to assist in disaster relief efforts. Required by Law. We may use or disclose your health information when we are required to do so by law. Public Health Activities. We may disclose your health information for public health activities, including disclosures to: • Prevent or control disease, injury or disability • Report child abuse or neglect; • • • • Report reactions to medications or problems with products or devices; Notify a person of a recall, repair, or replacement of products or devices; Notify a person who may have been exposed to a disease or condition; or Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. National Security. We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody the protected health information of an inmate or patient. Secretary of HHS. We will disclose your health information to the Secretary of the U.S. Department of Health and Human Services when required to investigate or determine compliance with HIPAA. Worker’s Compensation. We may disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law. Law Enforcement. We may disclose your PHI for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order. Health Oversight Activities. We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws. Judicial and Administrative Proceedings. If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute, Pinellas Family Dental 120 1st Ave SW Largo, FL 33770 but only if efforts have been made, either by the requesting party or us, to tell you about the request or to obtain an order protecting the information requested. Research. We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information. Coroners, Medical Examiners, and Funeral Directors. We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties. Fundraising. We may contact you to provide you with information about our sponsored activities, including fundraising programs, as permitted by applicable law. If you do not wish to receive such information from us, you may opt out of receiving the communications. Other Uses and Disclosures of PHI Your authorization is required, with a few exceptions, for disclosure of psychotherapy notes, use or disclosure of PHI for marketing, and for the sale of PHI. We will also obtain your written authorization before using or disclosing your PHI for purposes other than those provided for in this Notice (or as otherwise permitted or required by law). You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization. Your Health Information Rights Access. You have the right to look at or get copies of your health information, with limited exceptions. You must make the request in writing. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice. If you request information that we maintain on paper, we may provide photocopies. If you request information that we maintain electronically, you have the right to an electronic copy. We will use the form and format you request if readily producible. We will charge you a reasonable cost-based fee for the cost of supplies and labor of copying, and for postage if you want copies mailed to you. Contact us using the information listed at the end of this Notice for an explanation of our fee structure. If you are denied a request for access, you have the right to have the denial reviewed in accordance with the requirements of applicable law. Disclosure Accounting. With the exception of certain disclosures, you have the right to receive an accounting of disclosures of your health information in accordance with applicable laws and regulations. To request an accounting of disclosures of your health information, you must submit your request in writing to the Privacy Official. If you request this accounting more than once in a 12- month period, we may charge you a reasonable, cost-based fee for responding to the additional requests. (727) 518-8349 Phone (727) 518-8339 Fax www.dentalflorida.com Right to Request a Restriction. You have the right to request additional restrictions on our use or disclosure of your PHI by submitting a written request to the Privacy Official. Your written request must include (1) what information you want to limit, (2) whether you want to limit our use, disclosure or both, and (3) to whom you want the limits to apply. We are not required to agree to your request except in the case where the disclosure is to a health plan for purposes of carrying out payment or health care operations, and the information pertains solely to a health care item or service for which you, or a person on your behalf (other than the health plan), has paid our practice in full. Alternative Communication. You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. We will accommodate all reasonable requests. However, if we are unable to contact you using the ways or locations you have requested we may contact you using the information we have. Amendment. You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. If we agree to your request, we will amend your record(s) and notify you of such. If we deny your request for an amendment, we will provide you with a written explanation of why we denied it and explain your rights. Right to Notification of a Breach. You will receive notifications of breaches of your unsecured protected health information as required by law. Electronic Notice. You may receive a paper copy of this Notice upon request, even if you have agreed to receive this Notice electronically on our Web site or by electronic mail (e-mail). Questions and Complaints If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or if you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request We support your right to the privacy of your health information. 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. Telephone: (727) 518-8349 Fax: (727)518-8339 Address: 120 1st Ave SW, Largo, FL 33770 E-mail: [email protected] Reproduction of this material by dentists and their staff is permitted. Any other use, duplication or distribution by any other party requires the prior written approval of the American Dental Association. © 2010, 2013 American Dental Association. All Rights Reserved. Pinellas Family Dental 120 1st Ave SW Largo, FL 33770 (727) 518-8349 Phone (727) 518-8339 Fax www.dentalflorida.com Acknowledgement of Receipt of HIPAA Notice of Privacy Practices I have had full opportunity to read and consider the contents of Pinellas Family Dental’s HIPAA Notice of Privacy Practices. I am aware that I may request a copy of this notice at anytime. I understand that, by signing this consent form, I am giving my consent to use and disclose my protected health information to carry out treatment, payment activities, and health care operations. ________________________________ Signature _________________ Date I give Pinellas Family Dental permission to speak to the following people in regards to my treatment, care, account, and appointments. I may update the people listed at any time. Name:_________________________ Relationship:_________________ Phone:__________________ Name:_________________________ Relationship:_________________ Phone:__________________ Name:_________________________ Relationship:_________________ Phone:__________________ ________________________________ Signature _________________ Date Pinellas Family Dental 120 1ST AVENUE SW | LARGO FL, 33770 | (727) 518-8349 Written Financial Policy Thank you for choosing Pinellas Family Dental. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options. Payment Options: You can choose from: - Cash, Check, Visa®, MasterCard®, American Express® or Discover Card® We offer a 5% courtesy accounting adjustment to patients who pay for their treatment with Cash, Check or Credit Card prior to start of treatment for treatment plans of $500 or more. (Not to be combined with other discounts or savings plans) - Convenient Monthly Payment Options¹ from CareCredit Healthcare Credit Card and Lending Club Please note: Pinellas Family Dental requires payment at the beginning of your treatment. If you choose to discontinue care before treatment is complete, you will receive a refund less the cost of care received. For plans requiring more than 2 appointments, alternative payment arrangements may be provided. For patients with dental insurance we are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement for your treatment. If the amount paid by your insurance company differs from the amount estimated, the unpaid portion is the responsibility of the patient. Our assistance in filing of your insurance claim is in no way an acceptance of liability for unpaid claims. Any changes in your insurance policy or coverage must be brought to our attention prior to your dental visit. In addition, we cannot be responsible for the accuracy of the information given to us by your insurance company. If you have a question regarding your benefits, please contact your insurance company. By signing below, you hereby authorize responsible parties to pay directly to Pinellas Family Dental, any insurance benefits due to you for services rendered. You agree to be responsible for any balance remaining on the account after insurance payment. In the event that the insurance payment is not received within 45 days of the initial billing date, you will be responsible for payment in full of the balance due on your account. You hereby authorize said assignee to release all information and duplicate radiographs as necessary to secure payment. (A photocopy of this agreement is considered as valid as the original) Pinellas Family Dental charges $35.00 for returned checks. There will be a charge for appointments canceled without 24 hours notice. This charge will be according to your fee schedule. In the event that your account becomes delinquent you will be responsible for all court cost, attorney fees, and any additional fees necessary to collect the debt. If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need. Patient, Parent or Guardian Signature Patient Name (Please Print) ¹Subject to credit approval Date