New Patient Form
John C. Aniemeke D.D.S., M.S.
Referral Office: _________________________________________ Dr. ____________________________
Welcome to Live Oak Periodontics Thank you for selecting our dental team! Please fill out this form completely and if you have any questions or concerns do not hesitate to ask for assistance. We ask that you allow us to make a copy of your current valid driver's license and insurance card.
Name: ____________________________________________________________________ Date: _____________________________ Home Address: ________________________________________ City: ____________________ State: ___________ Zip: _____________ Date Of Birth: ________________________________ SSN# _____________________________ ID # _________________________
Cell Phone: _________________________________ Home # ________________________ Email:____________________________
Preferred communication: Home ________ Cell________ Wk _______ Text _______ Email _______________________________
Employer: _________________________________________________ Work # ______________________ Ext _______________
In case of emergency contact: _____________________________________ Phone _____________________ Relationship: ___________ Spouse or Parent Information:
Name: _________________________________________________ Date of Birth: ___________________ SSN# ____________________
Employer: _____________________________________________ Work # ______________________________ Ext # _______________ Insurance:
Name of policy holder: ___________________________________________________ Relationship : _____________________________ Insurance company: ____________________________________________ ID # __________________________ Group # ____________
Phone # ________________________________ Address: _____________________________________________ Zip: _______________ Family Dentist:
Location Name: ___________________________________________________ Doctor: ________________________________________ Address: ___________________________________________________ Zip: ________________ Phone: __________________________
I understand that accurate and complete diagnosis is an essential first step in my dental care and authorize Dr. John Aniemeke to perform diagnostic procedures as necessary to achieve an accurate and complete diagnosis. I also understand that effective diagnosis and treatment may necessitate the involvement of other health professionals in my care and therefore I authorize release of any information concerning my (or child’s) healthcare, advice and treatment to another dentist or physician. While I understand that I am ultimately responsible far all dental treatment fees. I would appreciate the office's assistance in submitting to my insurance company for reimbursement. I authorize release of any information concerning my(or child's) health care, advice or treatment provided for the purpose of evaluating and administering claims for insurance benefits and securing payment for treatment. I authorize payment of insurance benefits be made to Dr. John Aniemeke's office.
Signature of patient/parent: ___________________________________________________________ Date: _________________________
John C. Aniemeke, D.D.S, M.S
Live Oak Periodontics & Implant Dentistry. PLLC
12702 Toepperwein Rd., Suite 132
San Antonio, Texas 78233
(210)-209-7119
ACKNOWLEDGEMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICE
***You May Refuse to Sign This Acknowledgment***
I have received a copy of this office's Notice of Privacy Practice.
___________________________________________
(Please print name)
___________________________________________
(Signature)
___________________________________________
(Date)
For Office Use
We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, However acknowledgment could not be obtained because:
Individual refused to sign
_______ Communications barriers prohibited obtaining the acknowledgment _______ An emergency situation prevented us from obtaining acknowledgment
_______ Other (Please Specify) _________________________________________ ____________________________________________________________
John C. Aniemeke, D.D.S, M.S
Live Oak Periodontics & Implant Dentistry. PLLC
12702 Toepperwein Rd., Suite 132
San Antonio, Texas 78233
(210)209-7119
CONSENT FOR CLINICAL PHOTOS
Patient Name: __________________________________________ DOB: ____________________ If a Minor Parent or Legal Guardian: ________________________________________________
I consent to have my image to be taken by the staff at live Oak Periodontics & Implant Dentistry, PPL as described below:
I understand that photographs, videotapes, digital and other images may be recorded to document and assist with my care and the payment of my bill. These images may be used to assist in the education of fellow dentists. I understand that Live Oak Periodontics & Implants Dentistry, PLLC will own these images, but that I will be allowed access to view them or obtain copies of them at a reasonable cost. Other than for treatment, education, and payment purposes, images that identify me (or child) will be released and /or used outside the organization only upon written authorization from me or the patient representative.
If the images are to be taken for any other purpose other than treatment, education, or payment purposes the purpose must be stated: _____________________________________________________
I may revoke or withdraw this consent at any time. Such withdrawal of consent must be made in writing. Withdrawal of consent does not affect any information disclosed prior to the written notice of withdrawal.
I release and hold harmless Live Oak Periodontics & Implant Dentistry, PPLC, Its staff and employees from any and all claims or causes of action that I may have of any nature whatsoever, which may in any manner result from the use of the photograph or other images.
By signing below, I am indicating that I have read and understand the “consent for photography” form. I am either the patient or have the authority to give consent for the patient. My questions regarding this consent have been answered.
____________________________________________ _____________________________ Patient or Guardian Signature Date
____________________________________________ _____________________________ Printed Name Relationship to Patient
48 Hour Appointment Cancellation Policy
Live Oak Periodontics has a 48 hour cancellation/rescheduling policy. If an appointment is missed, canceled, or changed with less than a 48 hour business day notice a $50.00 charge will be added to the account. By signing below, you acknowledge that you have read and understand the Cancellation Policy for Live Oak Periodontics as described above. Thank you for your understanding and cooperation.
__________________________________ _______________ Signature Date
NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES |
Live Oak Periodontics & Implant Dentistry, PLLC
John C. Aniemeke, D.D.S., M.S.
12702 Toepperwein Rd Ste 132
San Antonio, Texas 78233
(210)-637-0306
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.
Understanding Your Health Record/Information
Each time you visit a hospital, physician or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:
⧫ basis for planning your care and treatment
⧫ means of communication among the many health professionals who contribute to your care ⧫ legal document describing the care you received
⧫ means by which you or a third-party payer can verify that services billed were actually provided ⧫ tool in educating health professionals
⧫ source of data for medical research
⧫ source of information for public health officials charged with improving the health of the nation ⧫ source of data for facility planning and marketing
⧫ tool with which we can assess and continually work to improve the care we render and the outcomes we achieve
Understanding what is in your record and how your health information is used helps you to: ⧫ ensure its accuracy
⧫ better understand who, what, when, where and why others may access your health information ⧫ make more informed decisions when authorizing disclosure to others
Your Health Information Rights
Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to:
⧫ request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522. Requests for restrictions on disclosure of PHI to your health plan for health care items or services paid for out-of -pocket must be accepted.
⧫ obtain a paper copy of the Notice of Privacy Practices upon request
⧫ inspect and obtain a paper or electronic copy of your health record as provided for in 45 CFR 164.524 ⧫ amend your health record as provided in 45 CFR 164.528 and HB300 (paper or electronic) ⧫ obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528 ⧫ request communications of your health information by alternative means or at alternative locations ⧫ receive a notice of a breach of "unsecured" protected health information
⧫ revoke your authorization to use or disclose health information except to the extent that action has already been taken
Our Responsibilities
This organization is required to:
⧫ maintain the privacy of your health information
⧫ provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
⧫ abide by the terms of this notice
⧫ notify you if we are unable to agree to a requested restriction
⧫ accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations
⧫ notify you of a breach of “unsecured” protected health information
We reserve the right to change our practices and to make the new provisions effective for all protected health information (PHI) we maintain. Should our information practices change, we will mail a revised notice to the address you have supplied us.
We will not use or disclose or sell your health information without your written authorization, except as described in this notice.
To Report a Problem
If you have questions and would like additional information, you may contact this office at (210)-637-0306.
If you believe your privacy rights have been violated, you can file a complaint with this office or with the secretary of Health and Human Services. There will be no retaliation for filing a complaint.
Examples of Disclosures for Treatment, Payment and Health Operations
Treatment: Information obtained by a nurse, physician or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment. We will also provide subsequent healthcare providers with copies of various reports that should assist them in treating you.
Payment: A bill may be sent to you or a third-party payer. This information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures and supplies used.
Health Operations:
1. Risk Management - Members of the medical staff or the risk or quality improvement staff may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.
2. Business Associates - There are some services provided in our organization through contacts with business associates. Examples include radiology, laboratory, copy services, transcription services, billing services, etc. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we have asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.
3. Notification – We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, of your location and general condition. 4. Communication With Family - Health professionals, using their best judgment, 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 payment related to your care.
5. Research - We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.
6. Funeral Directors – We may disclose health information to funeral directors consistent with applicable law to carry out their duties.
7. Organ Procurement Organizations – Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs for the purpose of tissue donation and transplant.
8. Marketing – We may contact you to provide appointment reminders or face-to-face information about treatment alternatives or other health-related benefits and services that may be of interest to you.
9. Food and Drug Administration (FDA) – We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, recalls, repairs or replacement. 10. Workers’ Compensation – We may disclose health information to the extent authorized by and to the extent
necessary to comply with laws relating to workers’ compensation or other similar programs established by law.
11. Public Health – As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.
12. Law Enforcement – We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.
13. Schools - We may disclose childhood immunization records to schools.
Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a workforce member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.
Effective Date: 10/07/2015