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Patient Intake Form

OraMax Oral Surgery & Maxillofacial & Implant

91 W. Schaumburg Rd.,
Schaumburg, IL, 60194
(847) 786-8000

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
  •  Yes
  •  No
  •  Yes
  •  No
  •  Part Time
  •  Full Time
DOCTOR AND REFERRAL INFORMATION( * mandatory to fill )
WHO WILL BE RESPONSIBLE FOR PAYMENT OF THIS ACCOUNT?( * mandatory to fill )
Insurance Information( * mandatory to fill )
  •  HMO
  •  PPO
  •  Neither
Primary dental insurance company( * mandatory to fill )
  •  Male
  •  Female
Primary medical insurance company( * mandatory to fill )
  •  Male
  •  Female
ORTHOGNATHIC HISTORY,SIGNS AND SYMPTOMS( * mandatory to fill )

( *Only be filled out for patients coming in for corrective jaw consultations)

Orthognathic surgery is treatment for a medical condition. Your medical insurance plan may provide coverage for orthognathic surgery. Your surgical treatment plan and clinical records can be presented by us to your carrier in order to determine benefit coverage and medical necessity. Part of establishing medical necessity is to present details about how your jaws affect various activities in your life.

Please indicate on this questionnaire what you think applies to you. The surgical treatment coordinator will discuss these items with you during your visit.

Thank you! 

EATING

  •  Cuts/tears food into small pieces
  •  Avoids crunchy foods
  •  Prefers softer foods

Chewing

  •  Left
  •  Right

Estimate how many teeth come together when chewing

  •  painful (bolus) swallowing
  •  drinks liquid with bite to ease swallowing
  •  choking episodes
  •  near-choking episodes
  •  upset stomach after meals
  •  daily
  •  4-5 week
  •  2-3 week
  •  2-3 month
  •  4-5 month
  •  None
  •  OTC
  •  Tums
  •  Rolaids
  •  prescription
  •  Prevacid
  •  Nexium
  •  Pepcid
  •  Other


  •  Difficult to bite with front teeth
  •  Unable to bite with front teeth
  •  Painful when biting
  •  Bites cheek tissue
  •  Bites tongue
  •  Places food farther back in mouth
  •  Sometimes gulps food
  •  Foods escape mouth when chewing
  •  Chews some foods a longer time
  •  Jaws become tired when eating
  •  Jaws become sore when eating


  •  Are you a restless sleeper?
  •  Do you suspect you may have sleep apnea?
  •  Have you been diagnosed with sleep apnea?
  •  Have you ever had a sleep study?
  •  Do you snore?


  •  Fine, no problems
  •  Stiff, tired, sore
  •  Painful
  •  Dry mouth
  •  Sore throat
  •  Gingival bleeding when brushing
  •  Headaches
  •  Medication for headaches
  •  1-2 week
  •  3-4 week
  •  >4 week


  •  During the night
  •  Have night guard
  •  Had night guard

DURING THE DAY

Clenching:

  •  During the day

Headaches:

  •  Headaches during the day
  •  1-2 week
  •  3-4 week
  •  >4 week
  •  Yes
  •  No


  •  Jaws tire when talking
  •  Difficulty pronouncing some words or phrases
  •  Some lisping
  •  Sometimes others ask me to repeat due to difficulty understanding some words or phrases


  •  Had/have nasal congestion
  •  Infrequently
  •  Occasionally
  •  Frequently
  •  Almost all the time
  •  Had/have sinus infections
  •  Mouth breather most of the time


  •  Popping or clicking
  •  Sometimes locks, open or closed
  •  Difficult to find comfortable position

FAMILY

  •  Yes
  •  No

HISTORY OF SYMPTOMS AND TREATMENTS

  •  Yes
  •  No

COMMENTS:

FOR OFFICE USE ONLY

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Health History( * mandatory to fill )

To our patients: Although oral surgeons primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking, could have an important interrelationship with the care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

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  •  No

HAVE YOU HAD OR DO YOU CURRENTLY HAVE.

 

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  •  No
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  •  Yes
  •  No
  •  Yes
  •  No
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MEDICATION( * mandatory to fill )
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
ALLERGIES( * mandatory to fill )

Are You Allergic to, or had a reaction to any of the following?

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
( * mandatory to fill )
  •  Yes
  •  No
  •  Yes
  •  No

Is there a FAMILY HISTORY of

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

IN CASE OF EMERGENCY, CONTACT:

IS THIS VISIT RELATED TO AN ACCIDENT? 

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Male
  •  Female
Women Only( * mandatory to fill )
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

Women Note: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control. 

 I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above, have been answered to my satisfaction. I will not hold my surgeon, or any other member of his / her staff, responsible for any errors or omissions that I have made In the completion of this form. 

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Office Use Only

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AUTHORIZATION( * mandatory to fill )

I authorize my surgeon and his / her designated staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x-rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment. This signature on file is my authorization for the release of information necessary to process my insurance claim if applicable. 

I hereby acknowledge that a copy of this office's Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice. 

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FEES AND PAYMENTS ( * mandatory to fill )

We make every effort to keep down the cost of your oral surgical care. We deliver the finest care at the most reasonable cost to our patients, therefore we request payment at the time service is rendered unless other arrangements have been made in advance. A parent or guardian must accompany a minor (patient). For your convenience, we accept Visa, Mastercard, and Discover. An estimate of the fees for any procedure or surgery you may require will be given to you upon request after your initial visit. Our staff will work with you to maximize your insurance reimbursement for covered procedures. If you have any dental and/or medical insurance we ask that you please complete the identifying information on this form and/or bring along your insurance identification cards. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. If procedure fees remain uncollected, you will be responsible for all collection costs, attorney's fees, and court costs. 

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Pharmacy Information( * mandatory to fill )
NOTICE OF PRIVACY PRACTICES( * mandatory to fill )

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. 

We are 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 September 1, 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 MAY WE USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU 

We may use and disclose your health information for different purposes, including treatment, payment, and healthcare operations. For each of these categories, we have provided a description and an example. Some information, alcohol and/or substance abuse records and mental health records may be entitled to special confidentiality protections under 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 of 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 replacements 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 authorize 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 Pill 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 authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for the government programs, and compliance with civil right 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 proves instituted by someone else involved in the dispute, 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 disclose PHI to funeral directors consistent with applicable law to enable them to carry out our duties.

Fundraising. We may contact you with information about our sponsored activities, including fundraising programs, as permitted by applicable law. If you do not wish to receive the communications. 

Other Uses and Disclosures of PHI 

Your authorization is required, with a few exceptions, for disclosure or 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. 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. 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. 

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 a satisfactory explanation of how payments will be handled under that 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, 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 notification 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 b 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. 

Release Of Medical Records( * mandatory to fill )

READ FIRST: Before you decide whether or not to let OraMax Oral Surgery share some of your confidential information with another agency or person, an advocate at OraMax Oral Surgery will discuss with you all alternatives and any potential risks and benefits that could result from sharing your confidential information. If you decide you want OraMax to release some of your confidential information, you can use this form to choose what is shared, how it's shared, with whom, and for how long.

I understand that OraMax Oral Surgery has an obligation to keep my personal information, identifying information, and my records confidential. I also understand that I can choose to allow OraMax Oral Surgery to release some of my personal information to certain individuals or agencies.

I, 

authorize OraMax Oral Surgery to share the following specific information with:

Who I want to have my information:

  •  in person
  •  by phone
  •  by fax
  •  by mail
  •  by e-mail
  •  to Spouse


  •  I understand that electronic mail (e-mail) is not confidential and can be intercepted and read by other people.


  •  X-Ray
  •  Treatment Letter
  •  Medical Correspondance
  •  Financial Information

My treatment can be discussed with the following people:

Please Note: there is a risk that a limited release of information can potentially open up access by others to all of your confidential information held by OraMax Oral Surgery.



  •  That I do not have to sign a release form. I do not have to allow OraMax Oral Surgery to share my information. Signing a release form is completely voluntary. That this release is limited to what I write above. If I would like OraMax Oral Surgery to release information about me in the future, I will need to sign another written, time-limited release.
  •  That releasing information about me could give another agency or person information about my location and would confirm that I have been receiving services from OraMax Oral Surgery.
  •  That OraMax Oral Surgery and I may not be able to control what happens to my information once it has been released to the above person or agency, and that the agency or person getting my information may be required by law or practice to share it with others.

I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either orally or in writing.

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