Patient Information & Health Information

Welcome to Advanced Endodontics, LLC Welcome to Advanced Endodontics, LLC

Please take a few minutes to complete this form as thoroughly as possible. If you have any questions, please ask. We will be happy to assist you in any way.

First Name

Last Name

Middle

Address

City

State

Zip

Home Phone No.

Work Phone No.

Cell Phone No.

Social Security No.

Birthdate

Occupation

Employed By

Spouse

Employed By

Spouse Work Phone No.

Notify in case of emergency

Phone No.

Your general dentist

You were referred by

PRIMARY DENTAL INSURANCE

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For Office Use Only

Basic

Major

Max

Ded

SECONDARY DENTAL INSURANCE

Add new row

For Office Use Only

Basic

Major

Max

Ded

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

SECTION A: PATIENT GIVING CONSENT

Name

Address

City

State

Zip

Telephone No.

SECTION B: TO THE PATIENT – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of you protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices from our staff at any time. If you have any questions please refer to:

Contact Person: Dr. Danna Saidon – Privacy Officer

Address: 231 Farmington Avenue, Farmington, CT 06032

Telephone: (860) 284-1032 Fax: (860) 284-9067

I give my consent to sharing my health information as needed with the following

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

If this Consent is signed by a personal representative on behalf of the patient, complete the following:

Personal Representative’s Name

Relationship to Patient

Your information will be encrypted.