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Ocotillo Dental Care

Christopher Chaffin, DDS

Welcome to Ocotillo Dental Care. Please fill out this form completely and print clearly. If you have any questions we will be glad to help you.

Form Section 1

Patient Information:

Today’s Date: *

Name: *

Nickname:

Home Address: *

City: *

State: *

Zip: *

Sex: *

Male Female

Age:

Birthdate: *

Marital status: *

Single Married Divorced Widowed

Patient SS#: *

Best time and place to reach you

Cell Phone: *

Occupation: *

Employer: *

Employer phone:

E-mail Address: *

Driver’s License#: *

Home phone:

If the patient is a student: School:

Grade:

How did you hear of us? (passed by office, web site, person’s name): *

In case of Emergency, Contact: Name *

Relationship:

Phone: *

Account Information:

PERSON RESPONSIBLE FOR THIS ACCOUNT: *

Relationship: *

SS#:

Birthdate:

Driver’s License #:

Phone numbers: Home:

Work:

Cell:

Occupation:

Employer:

Employer phone:

Employer Address:

Primary Dental Insurance:

Name of Insured (PERSON WHO HOLDS THE INSURANCE): *

SS#:

DOB: *

Relationship to patient: *

Insurance Company Name: *

Grp #: *

ID#: *

Insurance Phone Number *

Claims Address *

Is patient covered by additional dental insurance? *

Yes No

Secondary Dental Insurance:

Name of Insured (PERSON WHO HOLDS THE INSURANCE): *

SS#: *

DOB: *

Relationship to patient: *

Insurance Company Name: *

Grp#: *

ID#: *

Insurance Phone Number *

Claims Address *

Assignment and Release:

I, THE UNDERSIGNED CERTIFY THAT I (OR MY DEPENDENT) HAVE INSURANCE COVERAGE AND ASSIGN DIRECTLY TO OCOTILLO DENTAL CARE, PC. ALL INSURANCE BENEFITS, IF ANY, OTHERWISE PAYABLE TO ME FOR SERVICES RENDERED. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY INSURANCE. I HEREBY AUTHORIZE THE DOCTOR TO RELEASE ALL INFORMATION NECESSARY TO SECURE THE PAYMENT OF BENEFITS. I AUTHORIZE THE USE OF THIS SIGNATURE ON ALL INSURANCE SUBMISSIONS. I FURTHERMORE UNDERSTAND THAT IF MY ACCOUNT BECOMES DELINQUENT, AND THIS OFFICE TURNS MY ACCOUNT OVER TO A COLLECTION AGENCY, I WILL BE RESPONSIBLE FOR ANY FEES THAT ARE INCURRED IN THE PROCESS, AS WELL AS THE BALANCE OWED.

Responsible Party: *

Relationship: *

Date: *

Ocotillo Dental Care

Christopher Chaffin DDS

Form Section 2

DENTAL HISTORY

Name: *

DOB:

Check the appropriate box if you have ever had or currently have the following:

Bad breath

Yes No

Grinding/Clenching teeth

Yes No

Bleeding or sore gums

Yes No

Dry Mouth

Yes No

Mouth Breathing

Yes No

Lip or cheek biting

Yes No

Fingernail biting

Yes No

Chewing ice

Yes No

Pain around ear or jaw

Yes No

Chewing on one side of mouth

Yes No

Food collection between teeth

Yes No

Mouth pain while brushing

Yes No

Loose teeth or fillings

Yes No

Clicking or popping of jaw

Yes No

Fever blisters in mouth or on lips

Yes No

Cold sores or growths in mouth

Yes No

Problems with extractions or surgery

Yes No

Excessive bleeding from an extraction

Yes No

Orthodontic Treatment (Braces)

Yes No

Periodontal Treatment (Gum Surgery)

Yes No

Dentures?

Patial (U/L) Full (U/L) No

Sensitivity to: (circle) cold heat sweets when biting where?

Reason for today’s visit:

Former Dentist:

City :

State:

Zip:

Date of last dental visit:

Date of last dental x-ray s taken:

How many and what type?

How often do you: Brush ?

Floss?

Have you ever had an unfavorable reaction to a local anesthetic?

Do you feel nervous about having dental treatment?

Do you have pain or any problems any where in your mouth?

Do you like y our smile?

Do you feel that it can be improved:

HEALTH HISTORY

Physician’s Name:

Phone:

Date of Last visit:

Check the appropriate box if you have ever had or currently have the following:

AIDS (HIV) *

Yes No

Artificial Heart Valve *

Yes No

Diet Pills/ Phen-Fen *

Yes No

Heart Murmur *

Yes No

Heart Problems *

Yes No

Describe

Bisphos meds (fosamax) *

Yes No

Congestive Heart Failure *

Yes No

Angina *

Yes No

Mitral Valve Prolapse *

Yes No

Pacemaker *

Yes No

Rheumatic Fever *

Yes No

Alcohol/drug abuse *

Yes No

Anemia *

Yes No

Fainting or dizziness *

Yes No

Arthritis, Rheumatism *

Yes No

Artificial Joints (knee, hip) *

Yes No

Asthma *

Yes No

Back Problems *

Yes No

Blood Disease *

Yes No

Blood Transfusion *

Yes No

Hepatitis: *

Yes No

Type

Cancer: *

Yes No

Type

Chemotherapy/ Radiation *

Yes No

Circulatory Problems *

Yes No

Cortisone Treatments *

Yes No

Cough, persistent or bloody *

Yes No

Diabetes *

Yes No

Epilepsy/ seizures *

Yes No

Swelling of feet or ankles *

Yes No

Glaucoma *

Yes No

Headaches *

Yes No

Herpes *

Yes No

Kidney Disease *

Yes No

Liver Disease *

Yes No

Low Blood Pressure *

Yes No

High Blood Pressure *

Yes No

MAOI drugs *

Yes No

Scarlet Fever *

Yes No

Shortness of Breath *

Yes No

Sinus Trouble *

Yes No

Skin Rash *

Yes No

Special Diet *

Yes No

Stroke *

Yes No

Swollen neck glands *

Yes No

Thyroid Problems *

Yes No

Tonsillitis *

Yes No

Tobacco use: *

Smoke Chew No

Tuberculosis *

Yes No

Tumor/growth on head/neck *

Yes No

Ulcer *

Yes No

Respiratory Disease (Lung) *

Yes No

Venereal Disease *

Yes No

Wear contact lenses *

Yes No

Weight change, unexplained *

Yes No

Man Women

Are you pregnant? *

Yes No

Are you nursing? *

Yes No

Using Birth Control Pills? *

Yes No

Tobacco use: amount?

how long?

Is there any condition not listed that y ou have?

MEDICATIONS:

Check here if you are not taking any medications: *

Yes No

List any medications you are currently taking: (Including Vitamins, Herbal medicines)

Pharmacy Name: *

Phone: *

ALLERGIES:

Check here if you have no known allergies: *

Yes No

(Food or Medicine)

CONSENT:

I, THE UNDERSIGNED CONSENT: The information on this questionnaire is accurate to the best of my knowledge. I understand this information will be used by the dentist to help determine appropriate dental treatment. If there is any change in medical status, I will inform the dentist. The undersigned hereby authorizes the doctor or doctor’s staff to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the patient’s dental needs. Refusal of diagnostic aids at any time will release the doctor of responsibility for early diagnosis. I also authorize the doctor to perform any and all forms of treatment, medication, and therapy that may be indicated.

Patient or Responsible Party (parent/guardian of minor) *

Date: *

Doctor’s Signature

Date:

Ocotillo Dental Care

Compassion and Quality

3165 South Alma School Road, Suite 26 Chandler, AZ 85248 (480) 855-1994

FINANCIAL POLICY

Form Section 3

In order for our staff to attend to your dental health needs on a more personal level, we have written this information guide. We hope it will make it easier to understand our office policy regarding your financial obligation. We will try and bill you at the appropriate time and file your insurance claims for you. My staff and I will strive to have open communications on all financial matters. If you have any questions or problems; please bring them to our attention. We are here to help.

Patient care is our primary goal.

1. For patients with insurance, as a courtesy we will file your insurance claim for you. If we do not have all your insurance information before the day of treatment you will expected to pay for the services in full. You will be ex-pected to pay your annual deductible and at each visit for treatment, any estimated co-payment, and any portion not covered by your insurance. Please understand that what we collect are only estimates and vou are ultimately responsible (or anv and all o{the cost ofvour dental care. After your dental claim is paid, you will be billed for the remaining balance.
2. If, after 90 days your insurance company has not paid on your claim, you will be billed for the entire balance. At this point, you will have to contact your insurance company for reimbursement. We will assist in any way possible but your full payment is due and you will have to go to the insurance company to get payment.
3: For all unpaid accounts after the 90 day period a late fee will be billed each month of $39.00 and a finance charge of2% on all unpaid balances will be ac-cessed per month until the balance is paid in full.
4. Our office reserves appointment times especially for you when you schedule them. If you are unable to make a scheduled appointment with our office, please notify us within 24 hours prior to your appointment, so that we may schedule another patient at that time. If there is less than 24 hour cancellation notification, there will be a $50.00 missed appointment charge.
5. We suggest that you know the limitations of your insurance. If you are lim-ited, by your insurance plan, to a certain number of visits per year or have contractual waiting periods; please keep track of this information. You will be held responsible for payment.
6. We accept MasterCard, VISA, cash, check, and money orders. Any check returned from the bank will be subject to a $45.00 charge and cash will be required for future visits.
7: In cases of divorce. The person that brings a minor to the office for dental care is responsible for all charges. Ocotillo Dental Care cannot be responsible to get payment from the other parent.
8: All first time visits and emergencies; Full payment is due at the time of service.
9: Please ask our office staff if you have any questions.

I, THE UNDERSIGNED CERTIFY THAT I (OR MY DEPENDENT) HAVE INSURANCE COVERAGE AND ASSIGN DIRECTLY TO OCOTILLO DENTAL CARE, PC. ALL INSURANCE BENEFITS, IF ANY, OTHERWISE PAYABLE TO ME FOR SERVICES RENDERED. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY INSURANCE. I HEREBY AUTHORIZE THE DOCTOR TO RELEASE ALL INFORMATION NECESSARY TO SECURE THE PAYMENT OF BENEFITS. I AUTHORIZE THE USE OF THIS SIGNATURE ON ALL INSURANCE SUBMISSIONS. I FURTHERMORE UNDERSTAND THAT IF MY ACCOUNT BECOMES DELINQUENT, AND THIS OFFICE TURNS MY ACCOUNT OVER TO A COLLECTION AGENCY, I WILL BE RESPONSIBLE FOR ANY FEES THAT ARE INCURRED IN THE PROCESS, AS WELL AS THE BALANCE OWED.

Name of the Patient or Guardian *

Date *

Ocotillo Dental Care, P.C.

HIPAA PRIVACY FORM 1

Form Section 4

Notice Of Privacy Practices

Purpose: This form, Notice of Privacy Practices, presents the information that federal law requires us to give our patients regarding our privacy prac-tices. {Note: this form may need to be changed to reflect the dental prac-tice’s particular privacy policies and/or stricter state laws.}

We must provide this Notice to each patient beginning no later than the date of our first service delivery to the patient, including service delivered electronically, after April 14, 2003. We must make a good-faith attempt to obtain written acknowledgement of receipt of the Notice from the patient. We must also have the No-tice available at the office for patients to request to take with them. We must post the Notice in our office in a clear and prominent lo-cation where it is reasonable to expect any patients seeking ser-vice from us to be able to read the Notice. Whenever the Notice is revised, we must make the Notice available upon request on or af-ter the effective date of the revision in a manner consistent with the above instructions. Thereafter, we must distribute the Notice to each new patient at the time of service delivery and to any person requesting a Notice. We must also post the revised Notice in our office as discussed above.

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. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 03/01/03 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. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available 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.

USES AND DISCLOSURES OF HEALTH INFORMATION

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect: We may 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 of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

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 of protected health information of inmate or patient under certain circumstances

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $0.25 for each page, $20.00 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003.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 these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. {You must make your request in writing.} Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

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.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

THE UNDERSIGNED CERTIFY THAT I (OR MY DEPENDENT) HAVE I, THE UNDERSIGNED CERTIFY THAT I (OR MY DEPENDENT) HAVE BEEN PROVIDED WITH A NOTICE OF PRIVACY PRACTICES

Name of the Patient or Guardian *

Date *

QUESTIONSAND 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 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.

Contact Officer: Christopher Chaffin DDS or Office Manager/Privacy Officer
Telephone: 480-855-1994, Fax: 480-855-0486, E-mail: ODC3165@mdofficemail.com
Address: 3165 S Alma School Rd, Suite 26, Chandler, AZ 85248

Ocotillo Dental Care, P.C.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I have received a copy of this office’s Notice of Privacy Practices. *

Please Print Name *

Date *

There is one electronic signature for all form sections, by signing the electronic signature, you re agreeing to all form sections: