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  • 1. Personal
  • 2. Medical
  • 3. Dental
  • 4. Cosmetic
  • 5. TMD/TMJ
  • 6. Replacment Teeth
  • 7. Comfort
  • 8. Health Problems
Hippa Consent:

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 

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 the Notice. We must follow the privacy practices as described below. This Notice will take effect on __________ 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 Privacy Officer, _________________________. Information on contacting us can be found at the end of this Notice. 

TYPICAL USES AND DISCLOSURES OF HEALTH INFORMATION 

We will keep your health information confidential, using it only for the following purposes: 

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 primart job functions. Everyone on 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 be involved 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 unpaid balances.

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, and 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/pr supplies unless you have advised us otherwise.

Healthcare 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 medical records staff, outside health or management reviewers and individuals performing similar activities.

Required by Law: We may use or disclose your health information when we are required to do so by law. (Court or administrative orders, subpoena, discovery request or other lawful process.) We will use and disclose your information when requested by national security, intelligence and other State and Federal officials and/or if you are an intimate or otherwise under the custody of law enforcement.

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. 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 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 disability.

Marketing Health-Related Services: We will not use your health information for marketing purposes unless we have your written authorization to do so.

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 officials.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders, including, but not limited to, voicemail messages, postcards or letters.

YOUR PRIVACY RIGHTS AS OUR PATIENT

Access: Upon written request, you have the right to inspect and get copies of your health information (and that of an individual for whom you are a legal guardian.) There will be some limited exception. If you wish to examine your health information, you will need to complete and submit an appropriate request form. Contact our Privacy Officer for a copy of the Request Form. You may also request access by sending us a letter to the address at the end of this Notice. Once approved, an appointment can be made to review your records. Copies, if requested, will be $1.00 for each page and the staff time charged will be $20.00 per hour including the time required to locate and copy your health information. If you want the copies mailed to you, postage will also be charged. If you prefer a summary or an explanation of your health information, we will provide it for a fee. Please contact our Privacy Officer for a fee and/or for an explanation of our fee structure.

Amendment: You have the right to amend your healthcare 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.

Non-routine Disclosures: 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 these are not available.) You have the right to a list of instances in which we, or our business associates, disclosed information for reasons other than treatment, payment or healthcare operations. You can request non-routine disclosures going back 6 years starting on April 14, 2003. Information prior to that date would not have to be released. ( Example: If you request information on May 15, 2004, the disclosure period would start April 14, 2003 up to May 15, 2004. Disclosures prior to April 14, 2003 do not have to be made available. )

Restrictions: 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 Privacy Officer if you want to further restrict access to your health care information. This request must be submitted in writing.

QUESTIONS AND COMPLAINTS

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 our Privacy Officer. 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 complain to us in writing. Request a Complaint Form from our Privacy Officer. 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 or with the U.S. Department of Health and Human Services.

HOW TO CONTACT US 

Practice Name: Angel I. Reyes DMD and Assoc. 
Privacy Officer: Joyce Welsh 
Telephone: 352-376-6366 Fax: 352-376-3099
E-Mail: info@reyesdentistry.com
Address: 3731 NW 40 th Terr. Suite A, Gainesville , FL 32606 

We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge receipt of this Notice. You may refuse this acknowledgement if you wish.

Electronic Signature (Spell out full name).
After the signature is submitted, then the questions will start.
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Personal Information:
First Name : Middle Initial :
Last Name : Marital Status:
Date of Birth: Sex:
Address: City:
State: Zipcode:
Social Security Number: E-mail:
Occupation: Home Phone:
Employer: Work Phone:
Can we call you at work? Cell Phone:
How were you referred to our office?:    
       

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Primary Physician's Name: Pharmacy Name:
Primary Physician's Phone: Pharmacy Phone:
Date of last visit: In case of emergency call:
Emergency Contact Phone: Relationship to Contact:

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DENTAL HISTORY
When was your last dental appointment: What was done:
Dentist's Name: Phone Number:
Last FMX: Last Panoramic:
       
Are your teeth sensitive to:
Heat: Yes No How often do you floss? Once a day Several times a week
Weekly Monthly Never
Cold: Yes No Have you noticed any gum swelling around any teeth Yes No
Sweets Yes No Do you have unpleasant taste, bad breath or odor in your mouth Yes No
Biting Pressure: Yes No Have you ever had any periodontal treatment? Yes No
Does your food catch between your teeth Yes No If Yes, when?
Date of last professional cleaning?: If Yes, when?
Do your gums bleed when you brush?: Yes No

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COSMETIC
How do you like your smile? Would you like your teeth straighter? Yes No
Is there anything else you would change about your teeth or smile? Would you like your teeth whiter? Yes No
Are there any old filling or dental work that you don't like looking at? Have you ever had orthodontic treatment done in the past Yes No
If Yes, when was it completed?    

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  TMD/TMJ  
  Have you ever experienced any discomfort, popping or locking in your jaw joint ? Yes No Does it hurt to open wide, chew, or yawn? Yes No  
  Do you grind or clench your teeth? Yes No Do you have frequent headaches, migraines, neck, or shoulder aches Yes No  
  Have you noticed any loose teeth or changes in your bite Yes No      

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  REPLACEMENT TEETH  
  Do you have any missing teeth Yes No How long have your teeth been missing?  
  Are you familiar with artificial implants ? Yes No Do you have any fixed bridges to replace these teeth? Yes No  
  How old are these bridges? Do you wear either partial or complete removable dentures? Yes No  
  How old are these dentures? Yes No If you do not wear dentures now, you think that you will someday? Yes No  

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  COMFORT  
  Do you have any dental fears? Yes No Specify:  
  Have you ever had a bad experience in a dental office that causes you anxiety or nervousness? Yes No Have you ever had nitrous oxide? Yes No  
  Have you ever had oral sedation? Yes No      

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HEALTH PROBLEMS
Do you have any health problems ? Yes No Specify:
Have you had medical surgery Yes No Please Specify:
Are you currently under a physician's care? Yes No Reason for care:
Are you currently taking any medication?: Yes No Please Specify (include all vitamins, drugs, and birth control):
Are you allergic to any medications?
 Please Specify:
Have you ever had a reaction to local anesthetic Yes No What medication do you pre-medicate with?
Do you require pre-medication with antibiotics before dental appointments Yes No Do you have a history of the Rheumatic Fever/Heart Murmur Yes No
Mitral Valve Prolapse?: Have you ever been afflicted with any of the Seizures/Epilepsy/Stroke?: Yes No
Do you have any artificial knees, hips, joints, or valves?: Heart Ailment?: Yes No
Please Specify: Asthma/Hay Fever?: Yes No
High blood pressure?: Yes No Diabetes?: Yes No
High cholesterol?: Yes No Thyroid Disease Yes No
Respiratory Disease Yes No Liver/Kidney Problems Yes No
Prolonged Bleeding?: Yes No Healing Complications Yes No
Do you take blood thinners or aspirin Yes No Hepatitis/HIV?: Yes No
Do you smoke tobacco? Yes No Are you taking any diet drugs? Yes No
Are you pregnant?: Yes No Drug or Alcohol abuse?: Yes No
Do you have any GI problems?: Yes No Are you concerned about the finances that may be required Yes No
Would you be interested in interest-free or long-term payment plans Yes No Are you concerned about the time that maybe involved for your needed work?: Yes No

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