amdentalstudio.com-All Forms

PATIENT INFORMATION
PATIENT NAME*

First NameLast Name
SOCIAL SECURITY NUMBER*
DATE OF BIRTH*

MonthDayYear
Date
HOME ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PHONE # *
Is this a cell phone number?

YesNo
Would you like confirmations sent via text?*

YesNo
EMAIL*
example@example.com
EMERGENCY CONTACT
EMERGENCY CONTACT PHONE
DENTAL INSURANCE INFORMATION
Insurance Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SUBSCRIBER NAME
SUBSCRIBER SOCIAL SECURITY NO.
SUBSCRIBER DATE OF BIRTH

MonthDayYear
Date
SUBSCRIBER ID NO.
INSURANCE GROUP NO.
GROUP NAME
INSURANCE CO. NAME
INSURANCE PHONE

DENTAL SERVICES FINANCIAL AGREEMENT
It is our desire to make dental treatment available and affordable to all patients with exceptional needs. To ensure we can maintain our high quality of service and keep our fees as low as possible, it is important that our patients and their families understand any financial responsibilities prior to treatment. Please review the following policies and procedures:

PAYMENT POLICY Payment is due upon receipt of statement following each mobile visit from one of our providers. Private dental insurance will be billed for our patients as a courtesy and a statement will be sent after insurance has been billed.
1. We accept cash, personal checks, and money orders.
2. Fees will apply for any checks that are returned by the bank.
DENTAL INSURANCE As a courtesy we will gladly file your claims and accept assignment of dental insurance benefits provided you agree to the following:
1. You must provide us with an insurance card and/or all of the information necessary to verify your coverage and file your claim.
2. Your insurance policy is a contract between you, your employer, and the insurance company. We are NOT a party to that contract. Our relationship is with you; not your insurance company.
3. You are responsible to pay our fees; not what your insurance company allows or considers “usual, customary and reasonable” (UCR), all of which vary from one company to another.
4. Although we may estimate your insurance benefits, we are not responsible for their accuracy. Knowledge of your benefits is entirely YOUR responsibility. Receiving our services indicates your acceptance of responsibility to pay.
5. All charges not paid by your insurance company are your responsibility regardless of the reason for nonpayment. Not all services we provide are covered benefits. Benefits differ from one company to another.
6. Treatment provided in another dental office during your current plan year may alter your co-payment due for services rendered by our providers. In such cases we are not able to track whether or not you have reached your yearly maximum benefits. Please call your insurance company if this applies to you.
7. There are many factors in determining patient responsibility where coordination of benefits between two insurance companies is involved. We CANNOT guarantee what the out of pocket expense will be.
8. Please understand that our responsibility is to provide you with treatment that best meets your needs, not to try to match your care to insurance plan limitations.
FINANCIALLY RESPONSIBLE PARTY:
Name:

First NameLast Name
I have read and understand this document in its entirety; outlining the financial policies of Exceptional Needs Dental Services and agree to these terms.
Signature of patient or parent/guardian:

Clear
Date

MonthDayYear
Date

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 IT CAREFULLY.

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) requires all health care records and other individually identifiable health information (protected health information) used or disclosed to us in any form, whether electronically, on paper, or orally, be kept confidential. This federal law gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information. As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

Without specific written authorization, we are permitted to use and disclose your health care records for the purposes of treatment, payment and health care operations.
- Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. Examples of treatment would include crowns, fillings, teeth cleaning services, etc.
- Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be billing your dental plan for your dental services.
- Health Care Operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would include a periodic assessment of our documentation protocols, etc.
In addition, your confidential information may be used to remind you of an appointment (by phone or mail) or provide you with information about treatment options or other health-related services including release of information to friends and family members that are directly involved in your care or who assist in taking care of you. We will use and disclose your protected when we are required to do so by federal, state or local law. We may disclose your PROTECTED HEALTH INFORMATION to public health authorities that are authorized by law to collect information, to a health oversight agency for activities authorized by law included but not limited to: response to a court or administrative order, if you are involved in a lawsuit or similar proceeding, response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested. We will release your PROTECTED HEALTH INFORMATION if requested by a law enforcement official for any circumstance required by law. We may release your PROTECTED HEALTH INFORMATION to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs. We may release PROTECTED HEALTH INFORMATION to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor. We may use and disclose your PROTECTED HEALTH INFORMATION when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat. We may disclose your PROTECTED HEALTH INFORMATION if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities. We may disclose your PROTECTED HEALTH INFORMATION to federal officials for intelligence and national security activities authorized by law. We may disclose PROTECTED HEALTH INFORMATION to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations. We may disclose your PROTECTED HEALTH INFORMATION to correctional institutions or law enforcement HIPAA/@Notice of Privacy Practices.doc officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals or the public. We may release your PROTECTED HEALTH INFORMATION for workers' compensation and similar programs.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.
You have certain rights in regards to your PROTECTED HEALTH INFORMATION, which you can exercise by presenting a written request to our Privacy Officer at the practice address listed below:
- The right to request restrictions on certain uses and disclosures of PROTECTED HEALTH INFORMATION, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
- The right to request to receive confidential communications of PROTECTED HEALTH INFORMATION from us by alternative means or at alternative locations.
- The right to access, inspect and copy your PROTECTED HEALTH INFORMATION.
- The right to request an amendment to your PROTECTED HEALTH INFORMATION.
- The right to receive an accounting of disclosures of PROTECTED HEALTH INFORMATION outside of treatment, payment and health care operations.
- The right to obtain a paper copy of this notice from us upon request.
We are required by law to maintain the privacy of your PROTECTED HEALTH INFORMATION and to provide you with notice of our legal duties and privacy practices with respect to PROTECTED HEALTH INFORMATION.

We are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all PROTECTED HEALTH INFORMATION that we maintain. Revisions to our Notice of Privacy Practices will be posted on the effective date and you may request a written copy of the Revised Notice from this office.

You have the right to file a formal, written complaint with us at the address below, or with the Department of Health & Human Services, Office of Civil Rights, in the event you feel your privacy rights have been violated. We will not retaliate against you for filing a complaint.

For more information about our Privacy Practices, please contact:

Amanda Lowenstein, DMD
320 Littleton Road
Parsippany, NJ 07054
(973) 334-6444
amdentalstudios@gmail.com

For more information about HIPAA or to file a complaint:

The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
877-696-6775 (toll-free)

ACKNOWLEDGMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES

* You May Refuse to Sign This Acknowledgement *
I, Name have received a copy of this office's Notice of Privacy Practices.
Please Print Name
Signature
Date

MonthDayYear
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}
____________________________

	Yes	No
1. Are you fearful of dental treatment?
2. Have you had an unfavorable dental experience?
3. Have you ever had complications from past dental treatment?
4. Have you ever had trouble getting numb or had any reactions to local anesthetic?
5. Did you ever have braces, orthodontic treatment or had your bite adjusted?
6. Have you had any teeth removed or missing teeth that never developed or lost teeth due to injury or facial trauma?

	Yes	No
7. Do your gums bleed or are they painful when brushing or flossing?
8. Have you ever been treated for gum disease or been told you have lost bone around your teeth?
9. Have you ever noticed an unpleasant taste or odor in your mouth?
10. Is there anyone with a history of periodontal disease in your family?
11. Have you ever experienced gum recession?
12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?
13. Have you experienced a burning or painful sensation in your mouth not related to your teeth?

	Yes	No
14. Have you had any cavities within the past 3 years?
15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
17. Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?
18. Do you have grooves or notches on your teeth near the gum line?
19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
20. Do you frequently get food caught between any teeth?

	Yes	No
21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
22. Do you feel like your lower jaw is being pushed back when you bite your back teeth together?
23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?
24. In the past 5 years, have your teeth changed (become shorter, thinner or worn) or have your bite changed?
25. Are your teeth becoming more crooked, crowded, or overlapped?
26. Are your teeth developing spaces or becoming more loose?
27. Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?
28. Do you place your tongue between your teeth or close your teeth against your tongue?
29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
30. Do you clench or grind your teeth together in the daytime or make them sore?
31. Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?
32. Do you wear or have you ever worn a bite appliance?

	Yes	No
33. Is there anything about the appearance of your teeth that you would like to change (shape, color, size)?
34. Have you ever whitened (bleached) your teeth?
35. Have you felt uncomfortable or self-conscious about the appearance of your teeth?
36. Have you been disappointed with the appearance of previous dental work?

PATIENT INFORMATION

DENTAL HISTORY

MEDICAL HISTORY

DENTAL SERVICES FINANCIAL AGREEMENT

FINANCIALLY RESPONSIBLE PARTY:

NOTICE OF PRIVACY PRACTICES

Smile Analysis Questionnaire

	Yes	No
1. hospitalization for illness or injury
2. an allergic or bad reaction to any of the following
aspirin, ibuprofen, acetaminophen, codeine
penicillin
erythromycin
tetracycline
sulfa
local anesthetic
fluoride
chlorhexidine (CHX)
metals (nickel, gold, silver)
latex
nuts
fruit
other
3. heart problems, or cardiac stent within the last six months
4. history of infective endocarditis
5. artificial heart valve, repaired heart defect (PFO)
6. pacemaker or implantable defibrillator
7. orthopedic implant (joint replacement)
8. rheumatic or scarlet fever
9. high or low blood pressure
10. a stroke (taking blood thinners)
11. anemia or other blood disorder
12. prolonged bleeding due to a slight cut (INR > 3.5)
13. pneumonia, emphysema, shortness of breath, sarcoidosis
14. chronic ear infections, tuberculosis, measles, chickenpox
15. asthma
16. breathing or sleep problems (e.g., sleep apnea, snoring, sinus)
17. kidney disease
18. liver disease
19. jaundice
20. thyroid, parathyroid disease, or calcium deficiency
21. hormone deficiency
22. high cholesterol or taking statin drugs
23. diabetes
24. stomach or duodenal ulcer
25. digestive or eating disorders (e.g., celiac disease, gastric reflux, bulimia, anorexia)
26. osteoporosis/osteopenia (e.g., taking bisphosphonates)
27. arthritis
28. autoimmune disease (e.g., rheumatoid arthritis, lupus, scleroderma)
29. glaucoma
30. contact lenses
31. head or neck injuries
32. epilepsy, convulsions (seizures)
33. neurologic disorders (ADD/ADHD, prion disease)
34. viral infections and cold sores
35. any lumps or swelling in the mouth
36. hives, skin rash, hay fever
37. STI/STD/HPV
38. hepatitis
39. HIV/AIDS
40. tumor, abnormal growth
41. radiation therapy
42. chemotherapy, immunosuppressive medication
43. emotional difficulties
44. psychiatric treatment
45. antidepressant medication
46. alcohol/recreational drug use

	Yes	No
47. presently being treated for any other illness
48. aware of a change in your health in the last 24 hours (e.g., fever, chills, new cough, or diarrhea)
49. taking medication for weight management
50. taking dietary supplements
51. often exhausted or fatigued
52. experiencing frequent headaches
53. a smoker, smoked previously or use smokeless tobacco
54. considered a touchy/sensitive person
55. often unhappy or depressed
56. taking birth control pills
57. currently pregnant
58. diagnosed with a prostate disorder

	Yes	No
Are you self-conscious about your teeth or smile?
Are any of your teeth yellow, stained or somewhat discolored?
Would you like your teeth to be whiter?
Are the edges of any teeth worn down, chipped or uneven?
Are any of your teeth turned, crooked, or uneven?
Do you have any gaps or spaces between your teeth?
Do any of your teeth appear too small, short, large or long?
Do you have any prior dental work that appears unnatural?
Do you have any crowns or bridges that appear dark at the edge of your gums?
Do you have any gray, black or silver (mercury) fillings in your teeth?
Are you missing any teeth?
Do you see any pitting or defects on the surfaces of your teeth?
Does the appearance of your smile inhibit you from laughing or smiling?
When being photographed, do you smile with your lips closed instead of flashing a full smile?
Are you self-conscious about your teeth or smile?
Are any of your teeth yellow, stained or somewhat discolored?
Would you like your teeth to be whiter?
Are the edges of any teeth worn down, chipped or uneven?
Are any of your teeth turned, crooked, or uneven?
Do you have any gaps or spaces between your teeth?
Do any of your teeth appear too small, short, large or long?
Do you have any prior dental work that appears unnatural?
Do you have any crowns or bridges that appear dark at the edge of your gums?

	Yes	No
In a slight smile, with your lips slightly parted, do the tips of your front teeth show?
In a full smile, is there anything you do not like about your smile?

	Yes	No
Do any teeth look too long or too short?
Do any teeth look too pointed or too flat?
Do any teeth have a shape you do not like?
In a full smile, does the top lip rise above the necks of the teeth so that the gums show?

	Yes	No
When you bite on your back teeth (when you swallow), do all the front teeth come into contact?
When you bite on your front teeth (biting a sandwich), do all the front teeth come into contact?
Are the upper front teeth straight (rather than crooked, overlapped, or protruding)?
Are the lower six front teeth straight?
Are the lower front teeth even in appearance?
Are the teeth of one color from top to bottom?
Do you like the color of your teeth?
Is one front tooth darker than the rest?
Do you have a "gummy" smile (too much of your gums show when smiling)?
Are your gums red, sore, puffy, bleeding or receded?
Do the front teeth contain fillings that are not matched with other teeth so they are noticed?
In a full smile, sometimes the back teeth show.
Are these teeth free of stains and discolorations?
Do the necks of any teeth have erosion (a ditched-in "V" appearance that can be seen or felt with the fingernail)?
Have the gums receded from the necks of the teeth (the bottom) anywhere?
Is the curvature of the gum tissue good around the teeth (half-moon shape)?

	Yes	No
Is your breath always pleasant?
Do you use mouthwash or some other treatment for bad breath?
Do you brush your tongue?
Do you have a problem with throat drainage or sinuses?
Is your mouth free from decay or gum disease that cause bad breath?

	Yes	No
Does anyone tell you that you snore?
Does your snoring annoy anyone?

	Nearly every day	3-4 times a week	1-2 times a week	1-2 times a month	Never or nearly never
How often do you snore?
Has anyone noticed that you quit breathing during your sleep?
How often do you feel tired or fatigued after your sleep?
During your waketime, do you feel tired, fatigued or not up to par?
Have you ever nodded off or fallen asleep while driving a vehicle?
Do you have High Blood Pressure?