PATIENT FORM

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PATIENT INFORMATION

www.engortho.com | info@engortho.com | 303 498-0351 | 970 542-2500

Children/Siblings:

EMERGENCY CONTACT

The office reserves the right to verify the credit status of potential patients seeking payment terms.

RESPONSIBLE PARTY INFORMATION

DENTAL INSURANCE INFORMATION

MEDICAL HISTORY

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DENTAL HISTORY

Female Patients Only

I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history.

Authorization for Use and Disclosure of Protected Health Information

COMPLETE ONLY IF ENG ORTHODONTICS MAY SHARE PATIENT INFORMATION WITH OTHERS SUCH AS STEPPARENTS, GRANDPARENTS, SPOUSE, FRIENDS, ETC. IF THERE IS NO ONE YOU WOULD LIKE TO SHARE YOUR INFORMATION WITH, LEAVE BLANK AND SIGN BOTTOM LINE.

l hereby authorize Eng Orthodontics to release information, as indicated below, to the following person(s) listed below.

I authorize Eng Orthodontics to contact the individual(s) listed above to convey information as listed above regarding the patient in the event that I am unable to be reached by Eng Orthodontics.

I understand that I may revoke/cancel this authorization by notifying Eng Orthodontics, in writin , of my intent to revoke authorization, or change the name(s) of those listed to whom the information is to be released.

Please note that if the patient is under the age of 18, a legal guardian must either be present during the initial consultation or must have this page filled out with the name of the individual(s) bringing the patient to the exam.

PRIVACY POLICY

This policy describes how medical/dental information about you may be used and disclosed and how you can get access to this information. Please read it carefully.

We understand that the privacy of your personal information is important to you. As your orthodontic office, we believe your right to privacy is a fundamental part of your treatment; as such, we want you to understand our privacy practices and procedures. Should you have any questions regarding these policies please do not hesitate to contact our office at (303)498-0351.

Information We Collect About You

We collect personal information about you and your family as part of our new patient process, during the course of your care, and from other health care entities you utilize, such as; other dentists and specialists, imaging facilities, laboratories, and your insurance company. This personal information includes items such as your name, address, phone number, birth date, social security number, employer, health history, insurance policy and coverage information and any information you provide. During the course of your treatment we will collect dental information regarding diagnosis, treatment plans, progress and any test results or films.

How Your Information Is Used

The personal and health information gathered may be used and disclosed with your general consent for purposes of treatment, payment, or routine health care operations. This means we may send your information to other dentists or facilities involved in your treatment as well as to your insurance company or a collection agency to obtain payment. This includes electronic submission of your information for insurance claim purposes. This also includes contact with you and your family to provide appointment reminders or information about treatment. Any other uses of your information require a signed authorization by you, the patient or guardian and can be revoked at any time with a written request. Eng Orthodontics does not sell patient information to any third party. In certain cases of public health interest we may be required to disclose certain information to local, state, or national health organizations or government agencies.

Safeguarding Your Personal and Health Information
We are required by law to (1) make sure that medical information that identifies you is kept private, (2) provide you with our privacy policy, and (3) follow the terms laid out in the privacy policy. As a means of protecting your privacy, we restrict access to your personal and health information only those employees who require the information to complete their jobs and provide quality service to you.

Eng Orthodontics maintains physical, electronic, and procedural safeguards to comply with state and federal regulations that guard your personal and health information. If you feel your privacy has been violated you have the right to file a complaint with the
Department of Health and Human Services. A complaint in no way will influence with your course of treatment with our office.

Changes to Our Privacy Policy
All new patients will review a copy of our privacy policy. Eng Orthodontics occasionally reviews the Privacy Policy and reserves the right to amend it. Notification of changes will be available at the front desk prior to the effective date of any changes.

Right to Restrict Use of Information

You have the right to request restrictions to our uses or disclosures of your personal or health informatio, although we are not required to agree to those restrictions. Once your request has been processed it will remain in effect until you request a change.

Patient Acknowledgement

I have reviewed Eng Orthodontics Privacy Policy and understand that my diagnostic records and my name may be used for educational and promotional purposes.

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