As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create. receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional  questions concerring your health. This information is vital to alow us to provide appropriate care for you, This office does not use this information to discriminate.

If you are completing this form for another person, what is your relationship to that person?

Do you have any of the following diseases or problems:

(Check DK if you Don't Know the answer to the question)

If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.

Dental Information

For the following questions, please mark (X) your responses to the following questions.

Medical Information

please select your response to indicate if you have or have not had any of the following diseases or problems

(Check DK if you Don't know the answer to the question)

WOMEN ONLY Are you:

Allergies. Are you allergic to or have you had a reaction to:

Please select your response to indicate if you have or have not had any of the following diseases or problems

Congenital heart disease (CHD)

Except for the conditionis listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD

NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above and that the information given on this  form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form

As a provider of medical services, we are required under the Health Insurance Act, to inform you of your rights to protect your personal health information. As a covered entity, we must inform all patients of their right regardless of insurance coverage.

OUR DUTY TO YOU

As your dental provider, we will do everything in our control to maintain your records and information in a secure and private manner.

We do reserve the right to change our policies, but you will be informed of any changes in advance. We will only release information about you and your treatment under specific circumstances. These include, but are not limited to the following:

TREATMENT: We may use your information during the course of the treatment. That includes releasing information to other dentists, physicians, other health care providers, and our staff. Our staff includes full and part-time employees, as well as, temporary personnel.

PAYMENT: We may disclose personal information about you and your treatment to third party carriers and payment processing entities. This includes insurance carriers, claims clearinghouses, collection agencies, and third-party administrators such as employee medical reimbursement accounts.

OPERATIONS: We may use your personal information in the course of operations of our office. This may include quality assurance/quality improvement reviews credentialing, training, and certification and accreditation activities.

MISCELLANEOUS USES: At certain times we may be required to use your information for other purposes than as described above. Examples of these uses include appointment reminders (text messages, emails, voice messages, and letters), abuse/neglect, national security, family and friends (only to the extent for use in healthcare operations or payment), and in some cases to law enforcement and court releases.

YOUR RIGHTS

RESTRICTIONS: You have the right to restrict, to request restrictions, or disclosure usage. We are not required to accept these restrictions but we will make a note of the request and honor that request if applicable.

ACCESS: You have the right to access your personal health information. A request for access must be made in writing. You may speak to our privacy officer to schedule an appointment to view your information. You may also request a copy of your personal health information. Our office requires a 24-hour notice to fulfill this request

AMENDMENT: You have the right to request that we amend your personal health information. Your request must be made in writing and explain what should be amended and that the rationale for such a request. We have the right to deny this request if we feel that it would render your information inaccurate. We will inform you of the decision to amend your information.

COMPLAINTS: Please contact our privacy officer for any questions or complaints. If you feel that we have violated your privacy you can submit a written complaint to the U.S. Department of Health and Human Services. We can provide you with the address upon request.

By signing below I acknowledge that I have received and reviewed the Notice of Privacy. I agree with the terms of this notice and understand my rights under this notice.

By signing below I consent for the use of my personal health information for treatment, payment, and operations and other uses as described in privacy notice.

I also understand that I have the right not to sign this agreement.

Section I: Financial Agreement and Assignment of Benefits

In consideration for the services to be rendered to me, I hereby assume full responsibility to pay for those services in accordance with the rates in effect at Accent Dental Group, to the extent that I am legally responsible for such payment. Payments that I am responsible for may include, but are not limited to, balance after insurance, non-covered services, and deductibles.

I hereby assign to Accent Dental Group, any and all benefits for services rendered under insurance policies, reimbursement, or prepaid healthcare plans. I acknowledge any balance not covered or paid for by such policies is my legal responsibility. I understand that I am required to inform Accent Dental Group of any change in my address, phone number or insurance plan.

THIS IS A LEGAL FINANCIAL AGREEMENT OF BENEFITS FORM. BE SURE ANY QUESTIONS YOU MAY HAVE ARE ANSWERED BEFORE YOU SIGN AT THE BOTTOM OF THE PAGE.

Section II: Receipt Acknowledgement for the Notice of Privacy Practices

have been made aware of the Notice of Privacy Practices for Accent Dental Group. I understand that this notice states how Accent Dental Group may use and disclose by Protected Health Information (“PHI”).

I UNDERSTAND THAT A COPY OF THIS NOTICE ID AVAILABLE UPON REQUEST.

Section III: Medical Records Release Forms

I understand that if I request a copy of my medical records to be sent to another doctor, I must allow 15 business days for processing from the time I submit my signed authorization. I understand that if I submit a disability form, Family Medical Leave Act form, or any other form that requires a doctor signature and/or specific information to be completed, I must allow 10 business days for processing.

hereby authorize Accent Dental Group to release any information, in the course of my treatment, necessary to process insurance claims and/or to any other requesting physician in reference to referrals or coordination of care.

Section IV: Release of Records to a Designated Third Party

In addition to my treating physicians and medical facilities, I authorize Accent Dental Group to release and discuss my medical/billing information and records to the following individuals: (This should include friends or family members responsible for picking up your records when you are unable to do so.) 

By signing below I am verifying that I have read each of the four sections on this page.

I understand each section and consent to and agree with the information stated in each section.