Gottesman - Health History and pharmacy

Patient Demographic Information
Prefix
- Mr.
- Ms.
- Mrs.
- Dr.
Name
First Middle Initial Last
Address
Street Address Apt. / Unit # City State ZIP Code
Home Phone
Work Phone
Ext.
Cell Phone
Email Address
I prefer to be contacted via:
Name of Emergency Contact
Contact Phone #
Patient Birthdate
Social Security # if needed for insurance
Referred By
Who referred you?
General Dentist
General Dentist's Phone #
Insurance Information
Please check this box if you don't have dental insurance
- No Dental Insurance
Dental Insurance
Insurance Co.
Name of Insured
Policy ID #
Relationship to Patient
Insured's Birthdate
Group Name
Group Number
Claims Address
Street Address Address Line 2 City State ZIP Code
Insurance Phone Number
Medical Insurance
Insurance Co.
Name of Insured
Policy ID #
Relationship to Patient
Insured's Birthdate
Group Name
Group Number
Claims Address
Street Address Address Line 2 City State ZIP Code
Insurance Phone Number

NOTICE OF PRIVACY PRACTICES
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.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that health providers keep your medical and dental information private. The HIPAA privacy rule states that health providers must also practice with a written Notice of Privacy Practices. This notice is dated January 2008. The Privacy Practices described will be in effect after this date and until they are replaced. You may obtain additional copies of this Notice upon request.

Uses and Disclosure Information

Treatment Services
We may use or provide your health information to all of our staff members, other dentists, your physicians, and/or other healthcare providers taking care of you. We may also provide mail, phone or electronic contacts as appointment reminders, recommendation of treatment alternatives, information about other health services and/or other office services.

Payment and Operations
We may provide your health information as required to allow for payment for services and participation in quality assurance, disease management, training, licensing, and certification programs.

Marketing
We will not use your health information for marketing purposes without your written consent.

Legal Requirements
We may disclose your health information when required by law.

Patient Rights
You have the right to see your information and receive copies of your records under most circumstances. Your request must be in writing and addressed to the Office Manager. You may be charged for the cost of making copies, staff time and postage. A summary of your health information can also be requested for a fee. You may request a listing of any situations where we or our business associates disclosed your health information for purposes other than treatment, payment, or other activities for the last six years. You may be charged for costs associated with our response.

Threat to Health and Safety
If abuse or neglect is reasonably suspected we may disclose your health information to the appropriate government authorities.

National Security
Information may be given to authorized federal officials when required for intelligence and national security activities.

Family Members, Friends & Others Involved in Care
At your request, we may disclose your health information to a family member or other person if necessary to assist with your treatment and/or payment for services. Based on our judgement as per 164.522[a] of HIPAA we may disclose your information to these persons in the event of an emergency situation. We also may make information available so that another person may pick up filled prescriptions, medical supplies, records, or x-rays on your behalf. Your information may be disclosed to assist in notifying a family member, care-giver, or personal representative of your location or condition. You may request that we observe additional restrictions on the disclosure of your information. We are not required to agree to these restrictions but we may do so (except in case of an emergency).

By signing this form, I confirm that I have had the opportunity to receive a copy of the Notice of Privacy Practices.
Print Name
Date3
Signature

Appointment Cancellation Policy
We understand that unplanned issues can come up and you may need to cancel an appointment. If that happens, we respectfully ask for scheduled appointments to be cancelled at least 24 hours in advance.

Our doctors and hygienists want to be available for your needs and the needs of all our patients. When a patient does not show up for a scheduled appointment, another patient loses an opportunity to be seen. Therefore, there will be a fee of $100.00 if we do not receive a call to cancel an appointment within 24 hours.

Thank you for being a valued patient and for your understanding and cooperation as we uphold this policy. This policy will enable us to open otherwise unused appointments to better serve the needs of all patients.

Acknowledgment of Receipt of Appointment Cancellation Policy

By signing this form I confirm that I have had the opportunity to receive a copy of the Appointment Cancellation Policy.
Print Name
Signature
Date4

Pharmacy Information
Patient Name
Pharmacy Name
Address of Pharmacy
City, State, Zip
Pharmacy Phone #
Special Instructions (example: delivery, allergies)

Step 1 of 6

Patient Demographic Information

Insurance Information

Dental Insurance

Medical Insurance

Health Questionnaire

NOTICE OF PRIVACY PRACTICES

Appointment Cancellation Policy

Pharmacy Information