PATIENT INFORMATION

    Patient's Name
    Address
    City/State/Zip

    Employed By

    (If Student, Name School)

    Business Phone
    Male or Female
    Date of Birth
    Home Phone
    Cell Phone
    Social Security #
    Who referred you to our office?
    Person Responsible for Account
    Address
    City/State/Zip
    Phone
    S.S.#
    Relation to Patient

    PRIMARY INSURANCE COVERAGE

    Dental Insurance Company (If Any)
    Address
    Subscriber ID #
    Employee Name
    Employer Name
    Group #
    Date of Birth
    S.S.#
    Do you have Secondary Insurance Coverage?

    INSURANCE: To avoid misunderstanding regarding dental insurance, we wish our patients to know that all professional services rendered are charged direct to the patient and that patients are personally responsible for payment of fees. We will prepare necessary forms or reports to help you obtain your benefits from insurance companies, upon receipt of full (or partial) payment of bill. We do not render our services on the basis that insurance companies will pay all our fees. Each fee is individual for the individual payment.

    AUTHORIZATION: I hereby give Richard L. Dailey, DDS permission to file computer generated insurance forms without policy holder’s signature for dental treatment received.

    Signature

    (Parent/Guardian, if patient is a minor)

    Date

    HEALTH HISTORY

    1. Are you having any pain or discomfort at this time?

    yesno

    2. Are you under a physician’s care now?

    yesno
    Reason:
    Physician’s Name
    Phone #
    Address

    3. Are you currently taking any medications?

    yesno
    If yes, please list

    4. Are you allergic to any of the following?

    no
    Aspirin
    Tetracycline
    Novocaine
    Tetracycline
    Penicillin
    Xylocaine
    Erythromycin
    Sulfa Drugs
    Latex

    5. Are you allergic to any other other medication?

    yesno
    If yes, please list

    6. Mark any of the following you have had or have at present:

    Any Heart Ailments
    Arthritis
    Gastrointestinal problems
    High Blood Pressur
    Diabetes
    Malignancies
    Heart Murmur
    Kidney problems
    Heart Valve problem
    Asthma/Liver problems
    Lung problems
    Artificial Heart Valve
    Rheumatic Fever or Disease
    Thyroid problems
    Pregnancy,month
    Bleeding problems/Anemia
    Venereal
    Other
    Prosthetic Joint
    Excessive bleeding after cut/extraction

    7. Do you have any Immune System Disorder (AIDS, HIV, ARC)?

    yesno

    8. Women only – Are you taking Birth Control Pills?

    yesno
    Signature

    (Parent/Guardian, if patient is a minor)

    Date

    Dr. Richard Dailey

    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 (April 14, 2003), 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 any one 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 $0.50 for each page, $25.00 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: Richard L. Dailey, DDS

    Telephone: 336-513-0576 Fax: 336-513-0578

    Address: 807 Hermitage Road, Burlington, NC 27215

    Dr. Richard Dailey
    ACKNOWLEDGEMENT OF RECEIPT
    OF NOTICE OF PRIVACY PRACTICES

    **You May Refuse to Sign This Acknowledgement**

    I,
    , have received a copy of this office’s Notice of

    Privacy Practices.

    {Please Print Patient Name}

    Date

    {Signature}

    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)