UH Health Center Dental Office
100 UH Health Center, Building 525 713-­‐227-­‐6453 (main) / 713-­‐783-­‐2910 (fax) Patient Information Name: ______________________________ Birth Date: __________________________ Address: ____________________________ Marital Status: _______________________ _____________________________ Home #: ____________________________ City, State, Zip: _______________________ Cell #: ______________________________ Email: ______________________________ Work #: _____________________________ SSN: ________________________________ Sex: ________________________________ PeopleSoft Number: ___________________ How Did You Hear About Us ____ Electronic Signboard ____ Move In Packet ____ Health Center Website ____ Referred ____ Email Blast (Who may we thank: _____________) ____ Bus Stop Signage ____ Other ____ Event Table (Please specify: _________________) (Which event: __________________) Responsible Party Information Is patient own responsible party? Yes No Name: ______________________________ Email: ______________________________ Address: ____________________________ Home #: ____________________________ ____________________________ Cell #: ______________________________ City, State, Zip: _______________________ Work #: _____________________________ Insurance Information Does patient have primary dental insurance? Yes No Insurance Name: _____________________ Subscriber Name: _____________________ Phone #: ____________________________ Subscriber ID: ________________________ Group No./Name: _____________________ Subscriber Birth Date: _________________ Employer Name: ______________________ Relationship to Patient: ________________ Signature
I hereby authorize Service Provider to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit. Patient Or Guardian Name: _______________________________ Patient Or Guardian Signature: ______________________________ Date: _________________
UH Health Center Dental Office
100 UH Health Center, Building 525 713-­‐227-­‐6453 (main) / 713-­‐783-­‐2910 (fax) Medical Information
Reason for today’s visit: _____________________________________________________________________________ Date of last dental visit: ______________________________ Date of last dental x-­‐rays:__________________________ Are you under the care of a physician? __________________ Date of last doctor’s visit: __________________________ Doctor’s name and phone number (if applicable): ________________________________________________________ Have you ever been hospitalized? ______ If yes, for what condition: __________________________________________ Do you or have you ever used tobacco in any form? _______________________________________________________ Have you ever taken oral bisphosphonates or IV bisphosphonates (eg -­‐ Fosamax, Actonel, Boniva, Zometa, Aredia, Didronel, Skelid, Reclast)? ______________________________________ If yes, for how long: ____________________ WOMEN – Are you pregnant or nursing? ________________________________________________________________ Have you ever had psychiatric treatment or a nervous condition?_____________________________________________ Please list any medications you are taking: _______________________________________________________________ _________________________________________________________________________________________________ Do you have any history of: Y N Y N Y N Alcohol/Drug Abuse Emphysema Joint Replacement AIDS/HIV Infection Epilepsy Kidney/Bladder Trouble Anemia/Leukemia Fainting or Seizures Liver Disease Anorexia/Bulimia Fever Blisters/Herpes Low Blood Pressure Arthritis Frequent Headaches Mental Health Problems Asthma/Hay Fever Dry Mouth/Sjogren's Mitral Valve Prolapse Blood Clotting Problems Gag Reflex Rheumatic Fever Blood Transfusion Gall Bladder Trouble Sexually Transmitted Disease Bronchitis Heart Attack/Stroke Shortness of Breath Cancer/Tumor Heart Disease/Angina Sinus Trouble Cardiac Pacemaker Heart Murmur Thyroid Problems Chest Pain Upon Exertion Hepatitis Tuberculosis Contact Lenses Jaundice Frequent Urination Damaged Heart Valve High Blood Pressure Osteoporosis Diabetes (Type: I or 2 ) Hives/Skin Rash Do you have any other condition, illness, or problem not listed above? Please list:_______________________________ __________________________________________________________________________________________________ Please Initial Here: _____ UH Health Center Dental Office
100 UH Health Center, Building 525 713-­‐227-­‐6453 (main) / 713-­‐783-­‐2910 (fax) Last name: _________________________________________ Date of Birth: ___________________________ Are you allergic to any of the following: Y N Y N Y N Aspirin Latex Penicillin Codeine Local Anesthetics Sulfa Drugs Erythromycin Metals Other (please list): Iodine Epinephrine Dental Information
Do your gums bleed while brushing or flossing?.................................................................................................. yes no Are your teeth sensitive to hot, cold, or sweets?................................................................................................. yes no Have you had any head, neck, or jaw injuries?.................................................................................................... yes no Do you notice popping, clicking or soreness of the jaws?.................................................................................... yes no Do you clench or grind your teeth?...................................................................................................................... yes no Do you have problems with teeth/fillings breaking?........................................................................................... yes no Does food catch between your teeth?................................................................................................................. yes no Would you like your teeth to be whiter? …………………………………………………………………………………………..…………… yes no Would you like your teeth to be straighter? ………………………………………………………………………………………………….. yes no Have you ever had any problems with previous dental work? ………………………………………………………………………. yes no If yes, please explain: __________________________________________________________ Are you happy with your smile?........................................................................................................................... yes no If not, what would you like to change? ___________________________________________ Who may we contact in the event of an emergency? Name Phone Number Relationship to patient I certify that I have read and understand the above questions and acknowledge that questions have been answered to the best of my knowledge. Print Patient or Responsible Party Name: _____________________________________ Patient or Responsible Party Signature: ______________________________________ Date: _____________ Doctor’s Signature/Medical History Review: __________________________________ Date: _____________ UH Health Center Dental Office
100 UH Health Center, Building 525 713-­‐227-­‐6453 (main) / 713-­‐783-­‐2910 (fax) UH Dental Office Financial Information
Thank you for choosing us for your dental needs! We take pride in providing the ultimate in
convenience, while giving patients a premium dental experience at our state-of-the-art office. Cost of Treatment The experienced dentists at the UH Dental office provide considerable discounts to the UH community. PPO Dental insurance, student dental insurance and discounted cash rates for our office are the 3 payment options available to patients. If using insurance in any form it is the patient responsibility to provide that information at least 2 days prior to the appointment time unless scheduled within 24 hours of the appointment time. Treatment Estimates -­‐ Insurance When using insurance we provide treatment cost estimates to you based on information provided to us from your insurance company. Please remember that this is only an estimate of the cost of your care. As a courtesy for in-­‐
network patients, we will be happy to file claims with your insurance company on your behalf. Any patient co-­‐pays and co-­‐insurance are due in full on the day your dental care is provided. If you have any questions regarding your insurance benefits, we encourage you to contact your insurance company for further clarification. Your estimated insurance benefit may differ due to a number of reasons specifically related to your plan. This includes, but is not limited to: •
Exclusions and limitations of your insurance policy •
Waiting periods •
Use of alternative fee schedules by your insurance company •
Age restrictions •
Previous treatment already billed to your insurance company •
Specific treatment code restrictions •
Exceeding annual maximum benefits •
Insurance benefits are less than what was estimated In addition, you are solely responsible for any balances/fees incurred due to lack of action on your part. These can include, but are not limited to: •
Not complying with requests for insurance forms and/or signatures •
Not coming in to complete treatment resulting in non-­‐payment from my insurance company •
Lab costs incurred due to failure to appear at your scheduled appointments The cost of all dental care is ultimately the responsibility of the patient or their legal guardian. This is regardless of any insurance coverage. Missed Appointment/Cancellation Policy When appointments are booked, we are reserving doctor and chair time just for you. Cancellation must be made at least 24 hours prior to your scheduled appointment to prevent a late cancellation or no show fee of $30.00 by calling 713-­‐22-­‐SMILE (713-­‐227-­‐6453). UH Health Center Dental Office
100 UH Health Center, Building 525 713-­‐227-­‐6453 (main) / 713-­‐783-­‐2910 (fax) Cancellations can only be accepted during regular business hours. Weekends and holidays are not included in the 24-­‐hour cancellation period. Collection Policy Like other dental offices, accounts more than 60 days past due will be assessed a financing fee because of the delay in payment for services rendered. We reserve the right to run credit reports and send any accounts more than 90 days past due to a collection agency. I understand the above statements and agree to be financially responsible for my care, even in the event that my insurance company denies benefits. Print Patient or Guardian Name: ________________________________ Patient or Guardian Signature: ________________________________ Date: _______________ UH Health Center Dental Office
100 UH Health Center, Building 525 713-­‐227-­‐6453 (main) / 713-­‐783-­‐2910 (fax) Notice of Privacy Practices
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. THIS 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 (04/14/2003), 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, provide such changes are permitted by applicable law. We reserve the right to make changes in our
privacy practices and in 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 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 of other healthcare provider pending treatment to you.
Payment: We may use or disclose your health information to obtain payment for services we provided to you.
Healthcare operations: We may use or 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, and certification licensing or credentialing activities.
Our 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. You revocation will not affect any use of disclosures permitted by your authorization while it was in affect. Unless you give us 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 responsible inferences of your best interest in allowing a person to pick up filled prescriptions, medical
supplies, x-rays, or other 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.
UH Health Center Dental Office
100 UH Health Center, Building 525 713-­‐227-­‐6453 (main) / 713-­‐783-­‐2910 (fax) 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 the authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We
may disclose to correctional institutions or law enforcement officials 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 your 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 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 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, health operations and certain other activities, for the last six years, but not before April 14, 2003. If you request
this accounting more than once in 12-month period, we may charge you a reasonable, cost based fee for responding to these additional requests.
Restrictions: 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, 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 on 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 by using the contact information 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 to 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 the U.S. Department
of Health and Human Services.
For more information about HIPAA or to file a complaint:
The U.S. Department of Health and Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, DC 20201
202-619-0257
Toll free: 1-877-696-6775
UH Health Center Dental Office
100 UH Health Center, Building 525 713-­‐227-­‐6453 (main) / 713-­‐783-­‐2910 (fax) ACKNOWLEDGEMENT OF RECEIVING NOTICE OF PRIVACY PRACTICES
*You may refuse to sign this acknowledgement*
I, _________________________, have received the office’s Notice of Privacy
Practices.
Signature: __________________________
Date: __________