Adult HHF | Zombek Orthodontics (zombek) – Forms

Step 1 of 9 - Patient Information

Emergency Contact Information
Name * Required
First Middle Initial Last
Relationship to Patient * Required
- Mother
- Father
- Step-Mother
- Step-Father
- Guardian
Primary Phone * Required
Email
Person(s) OK to release appointment or medically related information to concerning child

Dental Insurance Information
Policy Owner Name * Required
Policy Owner Birthdate * Required
Relationship to Patient
SSN
Policy Owner's Address
(If same as patient's, you can say "Same as Patient's")

Street Address City State Zip Code
Policy Owner Phone * Required
Policy Owner Employer
Employer's Address
Street Address City State Zip Code
Insurance Company Name
Insurance Phone
Group Number
ID Number
Insurance Company Address
Street Address City State Zip Code
Do you have secondary dental insurance? * Required
- Yes
- No

Secondary Dental Insurance Information
If you have additional dental insurance you would like us to be aware of, please include that here. Otherwise, you can skip this section, and continue with your application.
Policy Owner Name
Policy Owner Birthdate * Required
Relationship to Patient
SSN
Policy Owner's Address
(If same as patient's, you can say "Same as Patient's")

Street Address City State / Province / Region ZIP / Postal Code
Policy Owner Phone * Required
Policy Owner Employer
Employer's Address
Street Address City State Zip Code
Insurance Company Name
Insurance Phone
Group Number
ID Number
Insurance Company Address
Street Address City State Zip Code

Notice of Privacy Policy
Our Legal Duty

We are required by applicable federal and state law to maintain the privacy of your health information. Protection of patient privacy is important to us. This notice summarizes the privacy practices that will be followed by our practice, We are 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 June 1st, 2020 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 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. For example, we may use or disclose your health information to another dentist, physician or other health care 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

Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. 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.

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 involved in your treatment to the extent necessary to help with your healthcare.

Persons Involved In Care

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. Electronic Filing: We may submit insurance claims electronically through our practice software.

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.
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 may also submit a written complaint with 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.
Patient Rights
Access

You have the right to look at or get copies of your health information, with limited exceptions. 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 $0.40 for each page and $14.00 per hour for staff time to 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 for a full explanation of our fee structure.

Disclosing Accounting

You may have the right to receive a list of instances in which your health information was disclosed for purposes other than treatment or certain other activities for the last 6 years, but not before January 1st, 2010. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, costbased fee for responding to these additional requests.

Alternative Communication

You may 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. We may agree to reasonable requests.

Amendment

You may 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 website or by e-mail, you are entitled to receive this Notice in written form.
Privacy Authorization
This Authorization is required by the privacy regulations promulgated by the United States Department of Health and Human Services. Your Protected Health Information (PHI) will be used or disclosed for the purposes of: LECTURES, PUBLICATIONS, RESEARCH and/or PRACTICE MARKETING. This information will be disclosed to the following people: all employees of this office. You have the right to revoke this authorization at any time in writing.

However, your revocation will not be effective to the extent that this authorization has been relied on. If your treatment will be used for research purposes, we may condition your treatment on obtaining this Authorization, in which case you may not receive treatment. The information used or disclosed per this Authorization may be subject to re-disclosure by the recipient(s), and thus, no longer protected by the privacy rules.
Consent * Required
I confirm that I have read, understand and agree to the privacy policy.
Our Legal Duty
We are required by applicable federal and state law to maintain the privacy of your health information. Protection of patient privacy is important to us. This notice summarizes the privacy practices that will be followed by our practice, We are 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 June 1st, 2020 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 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. For example, we may use or disclose your health information to another dentist, physician or other health care provider providing treatment to you.

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
Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. 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.

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 involved in your treatment to the extent necessary to help with your healthcare.

Persons Involved In Care
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. Electronic Filing: We may submit insurance claims electronically through our practice software.

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.

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 may also submit a written complaint with 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.

Patient Rights

Access
You have the right to look at or get copies of your health information, with limited exceptions. 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 $0.40 for each page and $14.00 per hour for staff time to 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 for a full explanation of our fee structure.

Disclosing Accounting
You may have the right to receive a list of instances in which your health information was disclosed for purposes other than treatment or certain other activities for the last 6 years, but not before January 1st, 2010. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, costbased fee for responding to these additional requests.

Alternative Communication
You may 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. We may agree to reasonable requests.

Amendment
You may 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 website or by e-mail, you are entitled to receive this Notice in written form.

Privacy Authorization
This Authorization is required by the privacy regulations promulgated by the United States Department of Health and Human Services. Your Protected Health Information (PHI) will be used or disclosed for the purposes of: LECTURES, PUBLICATIONS, RESEARCH and/or PRACTICE MARKETING. This information will be disclosed by the following people: all employees of this office. This information will be disclosed to the following people/entities: photographs will be on display for all patients and parents to view. You have the right to revoke this authorization at any time in writing. However, your revocation will not be effective to the extent that this authorization has been relied on. If your treatment will be used for research purposes, we may condition your treatment on obtaining this Authorization, in which case you may not receive treatment. The information used or disclosed per this Authorization may be subject to re- disclosure by the recipient(s), and thus, no longer protected by the privacy rules.

Office Guidelines
We require at least 24 hours notice to cancel an appointment. Any missed appointment will result in a $20.00 fee, which will need to be paid prior to any future appointments.

By signing this form, you agree that you understand that all charges for orthodontic treatment are due and payable at the time services are rendered, unless prior arrangements have been made. By signing this form, you also agree to authorize insurance benefits to be paid.

You agree that insurance portions are ESTIMATED based on information released by your insurance company. However, the estimate amount of insurance is NOT a guarantee of payment. You are aware that the insurance is a contract between yourself and your insurance carrier/provider. As a courtesy, claims may be filed on your behalf. If for some reason the insurance does not cover the benefit we have estimated, that difference will become the responsibility of the patient/parent/guardian.

You understand that you are financially responsible to the doctor(s) for all treatment.

Returned checks will result in a $35.00 charge to your account. In that case, only cash or credit card payments will be accepted from that point forward. Cell phones are not permitted in the treatment areas. Video recording is strictly prohibited.
Consent * Required
I confirm that I have read, understand and agree to the office guidelines.
We require at least 24 hours notice to cancel an appointment. Any missed appointment will result in a $20.00 fee, which will need to be paid prior to any future appointments.

By signing this form, you agree that you understand that all charges for orthodontic treatment are due and payable at the time services are rendered, unless prior arrangements have been made. By signing this form, you also agree to authorize insurance benefits to be paid.

You agree that insurance portions are ESTIMATED based on information released by your insurance company. However, the estimate amount of insurance is NOT a guarantee of payment. You are aware that the insurance is a contract between yourself and your insurance carrier/provider. As a courtesy, claims may be filed on your behalf. If for some reason the insurance does not cover the benefit we have estimated, that difference will become the responsibility of the patient/parent/guardian.

You understand that you are financially responsible to the doctor(s) for all treatment.

Returned checks will result in a $35.00 charge to your account. In that case, only cash or credit card payments will be accepted from that point forward.
Cell phones are not permitted in the treatment areas. Video recording is strictly prohibited.

Notice of Photo Release
I hereby acknowledge that I have been advised that photographs and images will be taken of me or my child, beforehand, during, and after procedures. The photographs will be taken by one of the members of our office. I hereby acknowledge that photographs may be taken during my, or my child’s, time in our office. I hereby give my consent for this office to use the photographs under the following circumstances: lectures, research, publications, internet advertising, on our website, on our social media outlets, or in any print advertising.

I grant this office and its employees, legal representatives, and associates the irrevocable and unrestricted right to use and publish photographs or video footage of me, or imagery in which I may be included, for editorial, trade, advertising, and web use. I also grant this office the right to alter any images or photographs without restriction and without my inspection or approval. I hereby release this office and their legal representatives from all claims and liability relating to said imagery.
Consent
I confirm that I have read, understand and agree to the notice of photo release.
I hereby acknowledge that I have been advised that photographs and images will be taken of me or my child, beforehand, during, and after procedures. The photographs will be taken by one of the members of our office. I hereby acknowledge that photographs may be taken during my, or my child’s, time in our office. I hereby give my consent for this office to use the photographs under the following circumstances: lectures, research, publications, internet advertising, on our website, on our social media outlets, or in any print advertising.

I grant this office and its employees, legal representatives, and associates the irrevocable and unrestricted right to use and publish photographs or video footage of me, or imagery in which I may be included, for editorial, trade, advertising, and web use. I also grant this office the right to alter any images or photographs without restriction and without my inspection or approval. I hereby release this office and their legal representatives from all claims and liability relating to said imagery.

Signature
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.

I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.
Signature * Required
Phone
This field is for validation purposes and should be left unchanged.

Step 1 of 9 - Patient Information

New Patient Form

Spouse/Additional Contact Information

Emergency Contact Information

Dental Insurance Information

Secondary Dental Insurance Information

Patient Medical and Dental History

Patient Medical History

Notice of Privacy Policy

Our Legal Duty

Uses and Disclosures of Health Information

Payment

Healthcare Operations

Your Authorization

To Your Family and Friends

Persons Involved In Care

Marketing Health-Related Services

Required by Law

Abuse or Neglect

National Security

Appointment reminders

Questions and Complaints

Patient Rights

Access

Disclosing Accounting

Alternative Communication

Amendment

Electronic Notice

Privacy Authorization

Office Guidelines

Notice of Photo Release

Signature