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Microsoft word - officeformsdrjohncarrolldds.doc

Patient’s Name _____________________________________ Date of Birth_____________ Age __________________ Must be present to complete this form Responsible Party’s Name ___________________________________________ Date of Birth ____________________ Adult Patient or Parent/Legal Guardian for minor patient or dependent adult Social Security # __________________________________________________ Marital Status ____________________ Phone (Home) _______________________ (Work) ________________________ (Cell) _________________________ Email ___________________________________________________________________________________________ Home Address ____________________________________________________________________________________ City __________________________________________ State ___________________ Zip ______________________ Employer ________________________________________________________________________________________ Emergency Contact Name __________________________________________ Phone __________________________ Insured’s Name __________________________________ Relationship to Patient ______________________________ Insured’s Date of Birth _______________________ SS# or Alternate Insurance ID# ____________________________ Insured’s Employer ________________________________________________________________________________ Insurance Company Name ____________________ Phone # _________________________Group # _______________ Address for Claims ________________________________________________________________________________ Annual Benefit ___________________ Deductible ___________________ Remaining Benefit ___________________ If you have SECONDARY DENTAL INSURANCE, or HEALTH INSURANCE with benefits for oral surgery, please complete the “SECONDARY INSURANCE” page. To the best of my knowledge, the above information, as well as all information that I provide on accompanying documents, is correct. I authorize Dr. John Carroll and members of his staff to use this information for purposes of creating a patient record and establishing an account for billing. I understand that, as the patient and/or responsible party, I am solely responsible for payment of any and all charges incurred by me for services rendered to the named patient. I authorize Dr. Carroll to bill me and/or the indicated insurance company(s) for any and all charges incurred by the named patient. Signature ____________________________________________________ Date ________________________ 26 West Dry Creek Circle · Suite 740 · Littleton · Colorado 80120 303 224 0500 ph 303 224 0606 fx DrJohnCarroll.com Patient’s Name _________________________________________ Patient’s Date of Birth _________________
Insured’s Name _________________________________________ Relationship to Patient ________________
Insured’s Date of Birth _____________________ SS# or Alternate Insurance ID# _______________________
Insured’s Employer _________________________________________________________________________
Insurance Company Name ____________________ Phone # __________________Group # _______________
Address for Claims _________________________________________________________________________
Annual Benefit ________________ Deductible _________________ Remaining Benefit _________________
HEALTH INSURANCE

Patient’s Name _________________________________________ Patient’s Date of Birth _________________
Insured’s Name _________________________________________ Relationship to Patient ________________
Insured’s Date of Birth _____________________ SS# or Alternate Insurance ID# _______________________
Insured’s Employer _________________________________________________________________________
Insurance Company Name ____________________ Phone # __________________Group # _______________
Address for Claims _________________________________________________________________________
Annual Benefit ________________ Deductible _________________ Remaining Benefit _________________
Signature ____________________________________________________ Date ________________________

Adult Patient or Parent/Legal Guardian for minor patient or dependent adult

26 West Dry Creek Circle · Suite 740 · Littleton · Colorado 80120 303 224 0500 ph 303 224 0606 fx DrJohnCarroll.com HEALTH HISTORY Patient’s Name ___________________________________________________ Who referred you to our office? ____________________ General Dentist ___________________ Orthodontist _______________ What is the purpose of your visit today?__________________________________________________________________________ Physician’s Name ___________________________________________________Telephone _______________________________ List all medications you are allergic to. __________________________________________________________________________ What medications you are taking? ______________________________________________________________________________ List previous hospitalizations and surgeries. _______________________________________________________________________ Please circle the appropriate response to each of the following: Hepatitis (A, B, C)
Y N Radiation
Y N Prosthetic
Y N Rheumatic
Prosthetic Heart Valve
Y N Bleeding
Disorders
___ Hemophilia A or B
___ von Willebrand's Disease
___ Blood Thinning Medications
___ Other _______________
Y N Emphysema/COPD
Y N Currently
Pregnant
I attest that the information provided in this health history is complete and accurate. Signature ___________________________________________ Date ______________________________ ______________________________________________________________________ ______________________________________________________________________ THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW 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 4/14/03, 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
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:
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
$0.75 for each page, $35.00 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.
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 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: John Carroll, D.D.S. or his designate
Telephone: (303) 224-0500
Address: 26 West Dry Creek Circle, Suite 740, Littleton, CO 80120
2002 American Dental Association All Rights Reserved
Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior
written approval of the American Dental Association.
This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).
______________________________________________________________________ ______________________________________________________________________ **You May Refuse to Sign This Acknowledgement**
I, ________________________________________, have received a copy of this office’s Notice of Privacy Practices. ______________________________________________________________________ {Please Print Name} ______________________________________________________________________ {Signature} ______________________________________________________________________ {Date} ___________________________________________________________________________________________________________
For Office Use Only
___________________________________________________________________________________________________________
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: • Individual refused to sign • Communications barriers prohibited obtaining the acknowledgement • An emergency situation prevented us from obtaining acknowledgement • Other (Please Specify) ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________
2002 American Dental Association All Rights Reserved
Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by
any other party requires the prior written approval of the American Dental Association.
This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).
___________________________________________________________________________________________________ CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION ___________________________________________________________________________________________________

SECTION A: PATIENT GIVING CONSENT

Name: __________________________________________________________________________________
Address: __________________________________________________________________________________
Telephone: ____________________________ E-mail: ____________________________________________
Patient Number: ________________________ Social Security Number: _______________________________
SECTION B: TO THE PATIENT—PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry
out treatment, payment activities, and healthcare operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this
Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures
we may make of your protected health information, and of other important matters about your protected health information. A copy of
our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy
practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of
your protected health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:
Contact Person: Dr. John A. Carroll Telephone: (303) 224-0500 Address: 26 West Dry Creek Circle, Suite 740, Littleton, CO 80120
Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted
to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on
this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke
this Consent.
B. SIGNATURE

I, ______________________________________________, have had full opportunity to read and consider the contents of this
Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your
use and disclosure of my protected health information to carry out treatment, payment activities and heath care operations.
Signature: ______________________________________________________________Date: _________________________
If this Consent is signed by a personal representative on behalf of the patient, complete the following: Personal Representative’s Name: Relationship to Patient: YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.
Include completed Consent in the patient’s chart.

Source: http://www.drjohncarroll.com/OfficeForms/OfficeFormsDrJohnCarrollDDS.pdf

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