551 5th Ave, RM 1114
New York, NY 10176
Phone: (212) 867-2730
Please fill out this form completely. If you have any questions we will
be glad to help you.
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)
(Check DK if you Don't Know the answer to the question)
Are you taking or scheduled to begin taking either of the medications,
alendronate (Fosamax®) or risedronate (Actonel®) for osteoporosis
or Paget’s disease? *
Since 2001, were you treated or are you presently scheduled to begin treatment
with the intravenous bisphosphonates (Aredia® or Zometa®) for bone
pain, hypercalcemia or skeletal complications resulting from Paget’s
disease, multiple myeloma or metastatic cancer? *
Are you allergic to or have you had a reaction to*
Please mark your response to indicate if you have or have not had any
of the following diseases or problems.
Except for the conditions listed above, antibiotic prophylaxis is no longer
for any other form of CHD.
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
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
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.
551 Fifth Avenue Suite 1114
New York, NY 10176
Phone: 212-753-0500 / Fax: 212-751-2073 / Email: firstname.lastname@example.org
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. State and federal laws require us to maintain the privacy
of your health information and to inform you about our privacy practices
by providing you with this notice. We must follow the privacy practices
as described below. This notice takes effect on January 1, 2018 and will
remain in effect until it is amended or replaced by us. It is our right
to change our privacy practices provided law permits the changes. Before
we make a significant change, this notice will be amended to reflect the
changes and we will make the new notice available upon request. We reserve
the right to make any changes in our privacy practices and the new terms
of our notice effective for all health information maintained, created,
and/or received by us before the date changes were made. You may request
a copy of our privacy notice at any time by contacting our front desk.
We will keep your health information confidential, using it only for the
Treatment: We may use your health information to provide you with our
professional services. We have established “minimum necessary”
or “need to know” standards that limit various staff members
access to your health information according to their primary job functions.
Every one of our staff is required to sign a confidentiality statement.
Disclosure: We may disclose and/or share your healthcare information with
other health care professionals who provide treatment and/or service to
you. These professionals will have a privacy and confidentiality policy
like this one. Health information about you may also be disclosed to your
family, friends, and/or other persons you choose to involve in your care,
only if you agree that we may do so.
Payment: We may use and disclose your health information to seek payment
for services we provide to you. This disclosure involves our business office
staff and may include insurance organizations or other businesses that
may become involved in the process of mailing statements and/or collecting
Emergencies: We may use or disclose your health information to notify,
or assist in the notification of a family member or anyone responsible
for your care, in case of any emergency involving your care, your location,
your general condition, or death. If at all possible we will provide you
with an opportunity to object to this use or disclosure. Under emergency
conditions or if you are incapacitated, we will use our professional judgment
to disclose only that information directly relevant to your care. We will
also use our professional judgment to make reasonable inferences of your
best interest by allowing someone to pick up filled prescriptions, x-rays,
or other similar forms of health information and/or supplies unless you
have advised us otherwise.
Health care operations: We will use and disclose your health information
to keep our practice operable. Examples of personnel who may have access
to this information include, but are not limited to, our dental records
staff, outside health or management reviewers and individuals performing
Required by law: We may use or disclose your health information when required
to do so by law, requested by national security, intelligence and other
State and Federal officials and/or if you are an inmate or otherwise under
the custody of law enforcement.
Abuse or neglect: We may use or disclose your health information to appropriate
authorities if we reasonably believe that you are a possible victim of
abuse, neglect, or domestic violence or the possible victim or other crimes.
This information will be disclosed only to the extent necessary to prevent
a serious threat to your health or safety or that of others.
Public Health responsibilities: We will use or disclose your health information
to report problems with products, reactions to medications, product recalls,
disease/infection exposure and to prevent and control disease, injury and/or
Marketing Health - Related services: We will not use your health information
for marketing purposes unless we have your written authorization to do
National Security: The health information of Armed Forces personnel may
be disclosed to military authorities under certain circumstances. If the
information is required for lawful intelligence, counterintelligence, or
other national security activities, we may disclose it to authorized federal
Appointment reminders: We may use or disclose your health information
to provide you with appointment reminders including, but not limited to
phone calls, voicemail messages, postcards, letter, emails or text messages.
Upon written request, you have the right to inspect and get copies of
you health information (and that of an individual for whom you are a legal
guardian.) There will be some limited exceptions. If you wish to examine
your health information, you will need to complete and submit an appropriate
request form. Contact our front desk for a copy of the request form. You
may also request access by sending us a letter or email at email@example.com.
Once approved, an appointment can be made to review your records. You have
the right to amend your health care information, if you feel it is inaccurate
or incomplete. Your request must be in writing and must include an explanation
of why the information should be amended. Under certain circumstances,
your request may be denied. You have the right to receive a list of non
routine disclosures we have made of your health care information. (When
we make a routine disclosure of your information to a professional for
treatment and /or payment purposes, we do not keep a record of routine
disclosures: therefore they are not available). You have the right to a
list of instances in which we, or our business associated, disclosed information
for reasons other than treatment, payment or healthcare operations. You
can request non routine disclosures going back 7 years starting January
1, 2018. Information prior to that date would not have to be released.
You have the right to request that we place additional restrictions on
our use or disclosure of your health information. We do not have to agree
to these additional restrictions, but if we do, we will abide by our agreement.
(Except in emergencies). Please contact our front desk if you want to further
restrict access to your health care information. This request must be submitted
in writing. You have the right to file a complaint with us if you feel
we have not complied with our privacy policies. Your complaint should be
directed to your doctor. If you feel we may have violated your privacy
rights, or if you disagree with a decision we made regarding your access
to your health information, you can contact and speak to your doctor directly.
We support your right to the privacy of your information and will not retaliate
in any way if you choose to file a complaint with us.
I acknowledge that I received a copy of Dr. David S. Binder’s Notice
of Privacy Practices.
Effective Date of Notice: 01/01/2018