HEALTH HISTORY

Patient’s Name Date of Birth Height Weight Today’s Date

______

Primary Care Physician Dentist OrthodontistALL RESPONSES ARE KEPT CONFIDENTIAL

Answer all questions by circling Yes (Y) or No (N)

Do you play any sports or exercise? ...... Y N

Do you have any shortness of breath with activity? ...Y N

If yes, how many city blocks can you walk?______

Date of last physical exam ......

  • Are you now under a physician’s care for

a particular problem?...... Y N

Please Describe:______

  • Have you ever had any serious illnesses,

operations or hospitalizations? If so, describe:...... Y N

DO YOU HAVE OR HAVE YOU EVER HAD:

A.Rheumatic Fever or Rheumatic Heart Disease?..Y N

B.Congenital Heart Disease?...... Y N

  1. Cardiovascular Disease (Heart Attack, Heart

Trouble, Heart Murmur, Coronary Artery Disease,

Angina, High Blood Pressure, Stroke, Palpitations,

Heart Surgery, Pacemaker)?...... Y N

  1. Lung Disease (Asthma, Emphysema, COPD, Chronic

Cough, Bronchitis, Pneumonia, Tuberculosis,

Shortness of Breath, Chest Pain, Severe

Coughing)?...... Y N

Last ER visit or Hospital Admission? ______

  1. Seizures, Convulsions, Epilepsy...... Y N
  2. Bleeding Disorder, Anemia, Bleeding Tendency,

Blood Transfusion? Do you bruise easily?...... Y N

G.Liver Disease (Jaundice, Hepatitis)?...... Y N

H.Kidney Disease?...... Y N

I.Diabetes?...... Y N

J.Thyroid Disease (Goiter)?...... Y N

K.Arthritis?...... Y N

L.Stomach Ulcers or Colitis?...... Y N

M.Glaucoma?...... Y N

  1. Osteoporosis?...... Y N
  2. Implants placed anywhere in your body

(Heart Valve, Pacemaker, Hip, Knee)?...... Y N

P.Radiation (X-ray) treatment for Cancer?...... Y N

Q.Clicking or popping of jaw joint (TMJ), pain,

difficulty opening mouth, grind or clench teeth?...Y N

R.Sinus or Nasal problems?...... Y N

  1. Any disease, drug or transplant operation

that has depressed your immune system?...... Y N

  • ARE YOU USING ANY OF THE FOLLOWING:

A.Antibiotics?...... Y N

B.Anticoagulants (Blood Thinners)?...... Y N

C.High Blood Pressure medications?...... Y N

D.Steroids (Cortisone, Prednisone, etc.)?...... Y N

E. Insulin or Oral Diabetic drugs?...... Y N

  • Past Surgical History:

______

Any personal or family history of surgical complication?

Malignant hyperthermia Y N

Nausea / Vomiting Y N

Prolonged bleeding Y N

Are you taking or have you ever taken Bisphosphonates (or monoclonal antibodies) for osteoporosis, multiple myeloma or other cancers (Reclast, Fosamax, Actonel, Boniva, Aredia, Zometa, Prolia, Xgeva, Denosumab) ? Y N

J.Have you ever been advisednot to take a medication?

...... Y N

K.Please list all medications, & DOSES for prescription medications, over-the-counter medications, herbs, vitamins:______

______

______

______

______

______

______

  • ARE YOU ALLERGIC TO OR HAVE YOU HAD AN ADVERSE REACTION TO:

A.Local Anesthesia (Novocain, etc.)?...... Y N

B.Penicillin...... Y N

Other antibiotics:

C.Aspirin or Ibuprofen?...... Y N

D.Codeine or other pain killers?...... Y N

E.Latex...... Y N

F. Lecithin ...... Y N

H.Other allergies or reactions? Please list...... Y N

Tobacco Use Y N Date quit:______

Smokeless tobacco Y N Date quit:______

Alcohol Use Y N Date quit:______

THC/Marijuana Y N Date quit:______

Other Drug Use Y N Date quit:______

  • Have you had any serious problems associated with

any previous dental treatment?...... Y N

Do you have any other disease, condition or

problem not listed above that you think the doctor

should know about?...... Y N

Do you wish to talk to the doctor privately

about anything?...... Y N

Have you ever had a bone density scan? ...... Y N

FOR WOMEN ONLY

A.Are you Pregnant, or is there any chance

you might be Pregnant?...... Y N

B.Are you nursing?...... Y N

C.When was your last menstrual cycle?______

D.If you are using Oral Contraceptives, it is important that you understand that antibiotics (and some other medications) may interfere with the effectiveness of oral contraceptives. Therefore, you will need to use mechanical forms of birth control for one complete cycle of birth control pills, after the course of antibiotics or other medication is completed. Please consult with your physician for further guidance.

I understand the importance of a truthful and complete Health History to assist my dentist in providing the best care possible. I have had the opportunity to discuss my Health History with my dentist.

X

DateSignature of Person Completing Health HistoryDoctor’s Initials

HEALTH HISTORY

Patient’s Name Date of BirthDate

Chief Dental Complaint: ______

______

Are you under the care of a physician?

Primary Care Physician______phone/fax #______

Cardiologist______phone/fax #______

Rheumatologist ______phone/fax #______

Other ______phone/fax #______

I have read and understand the above. Any questions I had about this form have been answered and I understand the answers. I understand it is my responsibility to fill out the form correctly and completely.

Date: ______Patient’s (or Guardian’s) Signature: X______

FOR COMPLETION BY THE DOCTOR

Significant findings from patient interview concerning medical history: ______

______

______

______

Dental Management Considerations:______

______

Consultations to obtain:

______

Date: ______Doctor’s Signature: ______

3/14

Leavenworth Oral and Maxillofacial surgery

Financial Policy

Thank you for choosing Leavenworth Oral and Maxillofacial Surgery as your oral surgery provider. Our primary mission is to deliver the best and most comprehensive care available. An important part of the mission is making the cost of optimal care as easy and as manageable for our patients as possible by offering several payment options, which are listed below.

Payment Options:

1.Cash

2.Check

3.Visa®, MasterCard®, Discover Card®, or American Express®

4.Convenient Monthly Payment Options¹ from CareCredit Healthcare Credit Card

- Allows you to pay over a period of time

- No annual fees or pre-payment penalties

Leavenworth Oral and Maxillofacial Surgery requires payment at the beginning of your treatment. If you choose to discontinue care before treatment is complete, you will receive a refund less the cost of care received.

For plans requiring multiple appointments, alternative payment arrangements may be provided.

Services rendered are fully the financial responsibility of the patient or account guarantor. As a courtesy, we will work with your insurance carrier (if applicable) to maximize your benefit for treatment reimbursement.² Any outstanding balance on the account is the patient’s responsibility. Should the insurance company send payment to the policy holder, payment must be forwarded to our clinic within 48 hours.

A fee of $50 is charged for patients who miss or cancel surgery appointments without 48-hour notice.

Leavenworth Oral and Maxillofacial Surgery charges $60 for returned checks.

Upon failure to provide payment for rendered service, three attempts will be made by our clinic to request payment. If no payment is received after the third attempt, the patient’s account will be submitted to the collections process; any cost incurred by our clinic to retrieve the overdue balance will be the patient’s responsibility.

Any violation of this agreement will, at the provider’s election, terminate patient charge privileges with provider and bring any balance owed by patient to provider immediately due and payable.

If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need.

Patient, Parent or Guardian Signature ______Date______

Patient Name (Please Print)______

¹Subject to credit approval

²However, if we do not receive payment from your insurance carrier within 60 days, you will be responsible for payment of your treatment fees and collection of your benefits directly from your insurance carrier.

First Name:______M.I.______Last Name:______

Dentist: ______Physician: ______Referral Source:______

Date of Birth:______Sex: □Male □Female Social Security #:______-______-______

Address:______City:______State:______Zip Code:______

Primary Phone:______(home/work/cell) Secondary Phone:______(home/work/cell)

Email Address:______¬¬¬______Marital Status: □Married □Single □Divorced □Separated

Student: □Full Time □Part Time □Not a Student Name of School:______

Employed: □Full Time □Part Time □Not Employed Name of Employer:______

EMERGENCY CONTACT: ______Relationship:______Phone:______

Who will be financially responsible for your account? (If self, continue to next section)

□Self □Mom □Dad □Spouse □Other Name: ¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬______Date of Birth:______

Address:______City:______State:______Zip Code:______

Primary Phone:______(home/work/cell) Secondary Phone:______(home/work/cell)

Email Address:______¬¬¬______Marital Status: □Married □Single □Divorced □Separated

Employed: □Full Time □Part Time □Not Employed Name of Employer:______

Dental Insurance Information:

Name of Insured Policyholder:______Relationship to Patient:______

Policyholder Date of Birth:______Social Security #:______-______-______

Name of Dental Insurance Carrier:______Dental Insurance Phone:______

Dental Insurance Address:______City:______State:______

Insured ID:______Group #______Group Name:______

Medical Insurance Information: If this information is the same as the Dental Insurance, leave this portion blank.

Name of Insured Policyholder:______Relationship to Patient:______

Policyholder Date of Birth:______Social Security #:______-______-______

Name of Medical Insurance Carrier:______Medical Insurance Phone:______

Medical Insurance Address:______City:______State:______

Insured ID:______Group #______Group Name:______

Leavenworth Oral & Maxillofacial Surgery

Card Oral & Maxillofacial Surgery Inc.

Patient Payment Agreement

Thank you for giving Leavenworth Oral and Maxillofacial Surgery the opportunity to serve as your oral surgery provider. We are excited to move forward in helping you obtain your oral health goals, and have created a treatment proposal personalized to your needs.

Patient Name:______

Guarantor Name:______

The estimated cost for your personalized treatment plan is $______.

The estimated patient portion due day of surgery is $______.

Once treatment has begun, changes in the anticipated treatment proposal may be required, depending on health conditions encountered. We will inform you if any changes in proposed treatment occur and you will be given the option of continuing or changing treatment. ______(initial)

As stated in Leavenworth Oral and Maxillofacial Surgery’s financial policy, the payment for the estimated patient portion is required, in full, by the surgery date. If you choose to discontinue care before treatment is complete, you will receive a refund less the cost of care received.

It is ESTIMATED that you insurance will cover $______. The amount covered by your specific insurance policy is an estimate, and not a guarantee of payment. Any discrepancies in the estimated amount and actual payment received will be the patient’s responsibility. Any questions regarding your insurance benefits or payments may be taken up with your insurance company.______(initial)

Your signature below forms a binding agreement between Leavenworth Oral and Maxillofacial Surgery (LOMS – the provider of medical services) and the patient who is receiving medical services, or the responsible party.

Patient, Parent or Guardian SignatureDate

Patient Name (Please Print)

(HIPAA) Notice of Privacy Practices for Protected Health Information (PHI)

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!

With your consent, the practice is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information (PHI) is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.

Example of uses of your health information for treatment purposes:

A nurse obtains treatment information about you and records it in a health record. During the course of your treatment, the doctor determines a need to consult with another specialist in the area. The doctor will share the information with such specialist and obtain input.

Example of use of your health information for payment purposes:

We submit a request for payment to your health insurance company. The health insurance company requests information from us regarding medical care given. We will provide information to them about you and the care given.

Example of Use of Your Information for Health Care Operations:

We obtain services from our insurers or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services.

Your Health Information Rights

The health record we maintain and billing records are the physical property of the practice. The information in it, however, belongs to you. You have a right to:

  • Ask someone who has medical power of attorney or your legal guardian, to exercise your rights and make choices about your health information.
  • Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office. We are not required to grant the request but we will comply with any request granted;
  • Request a restriction on disclosures of medical information to a health plan for purposes of carrying out payment or health care operations; and the PHI pertains solely to a health care service for which the provider has been paid out of pocket in full—we must comply with this request;
  • Request you be allowed to inspect your health record and billing record - you may exercise this right by delivering the request in writing to our office;
  • Obtain a copy of your paper or electronic record.
  • Appeal a denial of access to your protected health information except in certain circumstances;
  • Request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office;
  • File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information;
  • Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office. An accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing care;
  • Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office; and,
  • Elect to opt out of receiving further communications to raise funds for the practice.
  • Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office.

If you want to exercise any of the above rights, please contact [insert name of designated staff member, phone number, or address], in person or in writing, during normal hours. S[he] will provide you with assistance on the steps to take to exercise your rights.

Our Responsibilities

The practice is required to:

  • Maintain the privacy of your health information as required by law;
  • Provide you with a notice of our duties and privacy practices as to the information we collect and maintain about you;
  • Abide by the terms of this Notice;
  • Notify you if we cannot accommodate a requested restriction or request;
  • Accommodate your reasonable requests regarding methods to communicate health information with you;
  • We will never share your information (for marketing purposes, sale of your information, sharing of psychotherapy notes) without your written permission:, and
  • Notify you if you are affected by a breach of unsecured PHI

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our "Notice" or by visiting our office and picking up a copy.

To Request Information or File a Complaint

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contactour office at 913-772-4334. Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to our office manager. You may also file a complaint by mailing it or e-mailing it to the Secretary of Health and Human Services

  • We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the practice.
  • We cannot, and will not, retaliate against you for filing a complaint with the Secretary.

Other Disclosures and Uses

Notification

Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.

Communication with Family

Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person's involvement in your care or in payment for such care if you do not object or in an emergency.

Food and Drug Administration (FDA)

We may disclose to the FDA your protected health information relating to adverse events with respect to products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.

Workers Compensation

If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

Public Health

As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Abuse & Neglect

We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.

Correctional Institutions

If you are an inmate of a correctional institution, we may disclose to the institution, or its agents, your protected health information necessary for your health and the health and safety of other individuals.

Law Enforcement

We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement.

Health Oversight

Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.

Judicial/Administrative Proceedings

We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order.