Patient Forms PATIENT INFORMATION Gender: Male Female Family Status:MarriedSingleChildOther Birth Date: Prev. Visit: State:AL - AlabamaAK - AlaskaAZ - ArizonaAR - ArkansasCA - CaliforniaCO - ColoradoCT - ConnecticutDE - DelawareDC - District Of ColumbiaFL - FloridaGA - GeorgiaHI - HawaiiID - IdahoIL - IllinoisIN - IndianaIA - IowaKS - KansasKY - KentuckyLA - LouisianaME - MaineMD - MarylandMA - MassachusettsMI - MichiganMN - MinnesotaMS - MississippiMO - MissouriMT - MontanaNE - NebraskaNV - NevadaNH - New HampshireNJ - New JerseyNM - New MexicoNY - New YorkNC - North CarolinaND - North DakotaOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVT - VermontVA - VirginiaWA - WashingtonWV - West VirginiaWI - WisconsinWY - Wyoming PRIMARY DENTAL INSURANCE Insured's Birth Date: State:AL - AlabamaAK - AlaskaAZ - ArizonaAR - ArkansasCA - CaliforniaCO - ColoradoCT - ConnecticutDE - DelawareDC - District Of ColumbiaFL - FloridaGA - GeorgiaHI - HawaiiID - IdahoIL - IllinoisIN - IndianaIA - IowaKS - KansasKY - KentuckyLA - LouisianaME - MaineMD - MarylandMA - MassachusettsMI - MichiganMN - MinnesotaMS - MississippiMO - MissouriMT - MontanaNE - NebraskaNV - NevadaNH - New HampshireNJ - New JerseyNM - New MexicoNY - New YorkNC - North CarolinaND - North DakotaOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVT - VermontVA - VirginiaWA - WashingtonWV - West VirginiaWI - WisconsinWY - Wyoming State:AL - AlabamaAK - AlaskaAZ - ArizonaAR - ArkansasCA - CaliforniaCO - ColoradoCT - ConnecticutDE - DelawareDC - District Of ColumbiaFL - FloridaGA - GeorgiaHI - HawaiiID - IdahoIL - IllinoisIN - IndianaIA - IowaKS - KansasKY - KentuckyLA - LouisianaME - MaineMD - MarylandMA - MassachusettsMI - MichiganMN - MinnesotaMS - MississippiMO - MissouriMT - MontanaNE - NebraskaNV - NevadaNH - New HampshireNJ - New JerseyNM - New MexicoNY - New YorkNC - North CarolinaND - North DakotaOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVT - VermontVA - VirginiaWA - WashingtonWV - West VirginiaWI - WisconsinWY - Wyoming Patient's relationship to insured: Self Spouse Child Other State:AL - AlabamaAK - AlaskaAZ - ArizonaAR - ArkansasCA - CaliforniaCO - ColoradoCT - ConnecticutDE - DelawareDC - District Of ColumbiaFL - FloridaGA - GeorgiaHI - HawaiiID - IdahoIL - IllinoisIN - IndianaIA - IowaKS - KansasKY - KentuckyLA - LouisianaME - MaineMD - MarylandMA - MassachusettsMI - MichiganMN - MinnesotaMS - MississippiMO - MissouriMT - MontanaNE - NebraskaNV - NevadaNH - New HampshireNJ - New JerseyNM - New MexicoNY - New YorkNC - North CarolinaND - North DakotaOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVT - VermontVA - VirginiaWA - WashingtonWV - West VirginiaWI - WisconsinWY - Wyoming By checking this box, I authorize my insurance company to pay the dentist all insurance benefits rendered. I authorize the use of this electronic signature on all insurance submissions. I authroize the dentist to release all information necessary to secure the payment benefits. I understand that I am financially responsible for all charges whether or not paid by insurance. DENTAL INFORMATION Do your gums bleed when you brush or floss? Are your teeth sensitive to cold, hot, sweets or pressure? Does food or floss catch between your teeth? Is your mouth dry? Have you ever had periodontal(gum) treatement? Have you ever had orthodontic treatment? Have you had any problems associated with previous dental treatment? Is your home water supply fluoridated Do you drink bottled or filtered water? are you currently experiencing dental pain or discomfort? Do you have earaches or neck pains? Do you have any clicking, popping or discomfort in the jaw? Do you brux or grind your teeth? Do you have sores or ulcers in your mouth? Do you wear dentures or partials? Do you participate in active recreational activities? Have you ever had a serious injury to your head or mouth? Date of your last dental exam Date of last dental X-Rays MEDICAL HISTORY Are you under the care of a physician? YesNo Please check your response to indicate if you have or have had any of the following: Allergy Anesthetics Allergy Aspirin Allergy Codeine Allergy Latex Allergy Metals Allergy Other Allergy Penicillin Allergy Seasonal Allergy Sulfa Drug Anemia Arthritis Artificial Joints Asthma Autoimmune Disease Blood Disease High Blood Pressure Low Blood Pressure Cancer Diabetes Emphysema Epilepsy Excessive Bleeding Fainting/Dizziness Glaucoma Growths Head Injuries Heart Angina Heart Attack Heart Damaged Valves Other Heart Disease Heart Disease Heart Endocarditis Heart Failure Heart Murmur Heart Pacemaker Heart Rheumatic Heart Transplant Heart Valve Prolapse Cardiovascular Prosthetic Valve Hepatitis High Colesterol HIV/AIDS Jaundice Kidney Disease Liver Disease Liver Transplant Mental Disorder Nervous Disorder Neroulogical Disorder Pre-Medicates Radiation Treatment Respiratory Problems Rheumatic Fever Rheumatism Sinus Problem STD Stomach Problems Stroke Tuberculosis Tumors Ulcers Arteriosclerosis Systemic Lupus Erythematosus Bronchitis Chest Pain Upon Exertion Chronic Pain Eating Disorder Malnutrition Gastrointestinal Disease G.E. Reflux/Persistant Heartburn Thyroid Problems Sleep Disorder Mental Health Disorder Recurrent Infections Night Sweats Osteoporosis Persistant Swollen Glands in Neck Severe Headaches/Migraines Severe or Rapid Weight Loss Excessive Urination Have you had a serious illness, operation or been hospitalized in the past 5 years? YesNo Are you taking or have you recently taken any perscription or over the counter medicine(s)? YesNo Have you had an orthopedic total joint replacement? YesNo If yes, please provide date: Do you use controlled substances (drugs)? YesNo Do you use tobacco (smoking, snuff, chew, bidis)? YesNo Women, are you: Pregnant Nursing Taking birth control pills or hormonal replacement None of the above By checking this box, I acknowledge that above information is correct and I understand it is my responsibility to inform the office of any changes in my health as soon as possible. FINANCIAL POLICY Our team is delighted to welcome you to our practice and we are all pleased that you have chosen us to serve your dental needs. We are committed to the success of your treatment. Please understand that payment of your bill is considered part of your treatment. The following statement is our financial policy, which we request you to read and sign prior to services in our office. We will file your dental claim form as a courtesy to you. We will do all that we can to maximize your benefits. Please be aware that some of the services provided may be noncovered services or considered above the usual and customary. Insurance is never a guarantee of payment. It is the patient?s responsibility to know his or her insurance benefits. We do not file secondary insurance. In an effort to keep timely appointments, our office does not double book appointment times. Our time is reserved and dedicated solely to you. If you must change an appointment, please give us at least 48 hours notice, otherwise we reserve the right to charge you the $50 per hour broken appointment fee. Please help us to serve you better by keeping scheduled appointments. I consent to dental diagnosis and/or treatment by Dr. Barron. I understand that Dr. Barron will explain my options for attaining and maintaining optimal dental health. I understand that I am responsible for all fees incurred regardless of insurance coverage. I authorize assignment of benefits from and release of information to my insurance company applicable to treatment and insurance claims. I understand that payment is due at the time services are rendered. Any outstanding balance will be paid within 60 days. In the event that payment is not received with in that time, I agree to pay all costs of collections and/or late fees. My insurance coverage is an agreement between my insurance company and me. I also understand that all information will be held in the strictest confidence. By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the Office Financial Policy. NOTICE OF PRIVACY PRACTICES This notice describes how medical information about you may be used and disclosed, and how you can get access to this information, Please review carefully.If you have any questions about this Notice please contact our Privacy Officer or any staff member in our office. This notice of Privacy Practices describes how we may use and disclose your protected health information to carry out your treatment, collect payment for your care and manage the operations of this clinic. It also describes our policies concerning the use and disclosure of this information for other purposes that are permitted or required by law. It describes your rights to access and control your protected health information. “Protected Health Information” (PHI) is information about you, including demographic information that may identify you, that relates to your past, present, or future physical or mental health or condition and related health care services. We are required by Federal law to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. The new notice will be effective for all PHI that we maintain at that time. You may obtain revisions to our Notice of Privacy Practices by calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment. A. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION By applying to be treated in our office, you are implying consent to the use and disclosure of your PHI by your doctor, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your PHI may also be used and disclosed to bill for your health care and to support the operation of the practice. Uses and Disclosures of PHI Based Upon Your Implied ConsentFollowing are examples of the types of uses and disclosures of your protected health care information we will make, based on this implied consent. These examples are not meant to be exhaustive but to describe the types of uses and disclosures that may be made by our office.Treatment: We will use or disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that has already obtained you permission to have access to your PHI. For example, we would disclose your PHI, as necessary, to another physician who may be treating you. Your PHI may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. In addition, we may disclose your PHI from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your doctor, becomes involved in your care by providing assistance with your health care diagnosis or treatment.Payment: Your PHI will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for procedures may require that your relevant PHI by disclosed to the health plan to obtain approval for those services Healthcare operation: We may use and disclose, as needed, your PHI in order to support the business activities of this office. These activities may include, but are not limited to, quality assessment activities, employee review activities and staff training.For example, we may disclose your PHI to interns or precepts that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your doctor. Communications between you and the doctor or his assistants may be recorded to assist us in accurately capturing your responses. We may also call you by name in the reception area when your doctor is ready to see you. We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment. We will share your PHI with third party “Business Associates” that perform various activities (e.g., billing, transcription services for the practice). Whenever an arrangement between our office and a Business Associate involves the use or disclosure of your PHI, we will have a written agreement with that Business Associate that contains terms that will protect the privacy of your PHI.We may use or disclose your PHI, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also, use and disclose your PHI for other internal marketing activities. For example, your name and address may be used to send you a newsletter about our practice and the services we offer, we will ask for your authorization. We may also send you information about products or services that we believe may be beneficial to you. You may request that these materials not be sent to you.Uses and Disclosures of Protected Health Information That May Be Made With Your Written AuthorizationOther uses and disclosures of your PHI will be made only with your written authorization, unless otherwise permitted or required by law as described below. For example, with your written, signed authorization, we may use your demographic information and the dates that you received treatment from our office, as necessary, in order to contact you for fundraising activities supported by our office. You may revoke any of these authorizations, at any time, in writing, except to the extent that your doctor or the practice has taken an action in reliance on the use or disclosure indicated in the authorization.Other Permitted and Required Uses and Disclosures That May Be Made With Your Authorization or Opportunity to ObjectIn the following instance where we may use and disclose your PHI, you have the opportunity to agree or object to the use or disclosure of all or part of your PHI. If you are not present or able to agree or object to the use or disclosure of the PHI, then your doctor may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the PHI that is relevant to your health care will be disclosed.Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your PHI that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location or general condition. Finally, we may use or disclose you PHI to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care. Other Permitted and Required Uses and, Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to ObjectWe my use or disclose your PHI in the following situations without your consent or authorization. These situations include: Required by Law : We may use or disclose your PHI to the extent that the use of disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures. Public Health:We may disclose your PHI for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose you PHI, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority. Communicable Diseases: We may disclose your PHI, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. Health Oversight: We may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil right laws. Abuse or Neglect: We may disclose your PHI to a public authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your PHI if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable Federal and State laws.Legal Proceedings: We may disclose PHI in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process. Law Enforcement: We may also disclose PHI, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal process and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the Practice, and (6) medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred.Workers’ Compensation: We may disclose you PHI, as authorized, to comply with workers’ compensation laws and other similar legally-established programs.Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. Seq. B. YOUR RIGHTSFollowing is a statement of your rights with respect to you PHI and a brief description of how you may exercise these rights. You have the right to inspect and copy your PHI. This means you may inspect and obtain a copy of PHI about you that is contained in a designated record set for as long as we maintain the PHI. A “designated record set” contains medical and billing records and any other records that your doctor and the Practice uses for making decisions about you. Under Federal law, however, you may not inspect or copy the following records: psychotherapy notes: information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and PHI that is subject to law that prohibits access to PHI. Depending on the circumstances, a decision to deny access may be reviewed. In some circumstances, you may have a right to have this decision reviewed. Please ask your doctor if you have questions about access to your medical record. You have the right to request a restriction of your PHI. This means you may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment or healthcare operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must be in writing and state the specific restriction requested and to whom you want the restriction to apply. Your provider is not required to agree to a restriction that you may request. If the doctor believes it is in your best interest to permit use and disclosure of you PHI, your PHI will not be restricted. If you doctor does agree to the requested restriction, we may not use or disclose you PHI in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your doctor. You may request a restriction by presenting your request, in writing to a staff member in our office. The staff member will provide you with “Restriction of Consent” form. Complete the form, sign it, and ask that the staff member provide you with a photocopy of your request initialed by them. This copy will serve as your receipt. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing. You may have the right to have your doctor amend your PHI. This means you may request an amendment of PHI about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please ask your doctor if you have questions about amending your medical record. You have the right to receive an accounting of certain disclosures we have made, if any, of your PHI. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, to family members or friends involved in your care, pursuant to a duly executed authorization or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions and limits. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically. C. COMPLAINTSYou may complain to us, to the Texas Attorney General’s Office, or the Secretary of Health and Human Services, if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of you complaint. We will not retaliate against you for filing a complaint. Our Privacy Officer is Karen Crittenden. You may contact our Privacy Officer in writing at our office address or by calling 817-732-1626. Our website may offer additional information about the complaint process.This notice was published and becomes effective on February 1, 2016. By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the HIPAA Disclosure Form. Submit Form Your request has been sent -- we will be in contact with you shortly. 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