Leavenworth Oral & Maxillofacial Surgery
HEALTH HISTORY
Patient’s Name Date of Birth AGE Height Weight Today’s Date
__________________ _______________ ___________________
Primary Care Physician Dentist Orthodontist ALL RESPONSES ARE KEPT CONFIDENTIAL
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
o Are you now under a physician’s care for
a particular problem? Y N
Please Describe:__________________________________
o 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
C. Cardiovascular Disease (Heart Attack, Heart
Trouble, Heart Murmur, Coronary Artery Disease,
Angina, High Blood Pressure, Stroke, Palpitations,
Heart Surgery, Pacemaker)? Y N
D. 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? _______________
E. Seizures, Convulsions, Epilepsy Y N
F. 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
N. Osteoporosis? Y N
O. 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
S. Any disease, drug or transplant operation
that has depressed your immune system? Y N
o 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
o Past Surgical History:
o 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
Please list all medications, & DOSES for prescriptions, over-the-counter meds, herbs, vitamins: _______________________ _____________________
____________________ _____________________
____________________ _____________________
____________________ _____________________
____________________ _____________________
____________________ _____________________
____________________ _____________________
o ARE YOU ALLERGIC TO OR HAVE YOU HAD AN ADVERSE REACTION TO:
A. Local Anesthesia (Lidocaine, etc.)? Y N
B. Penicillin Y N
Other antibiotics: Y N
C. Aspirin or Ibuprofen? Y N
D. Codeine or other pain killers? Y N
E. Latex Y N
F. Lecithin Y N
Other allergies or reactions? 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:____________
o 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
Date Signature of Person Completing Health History Doctor’s Initials
HEALTH HISTORY
Patient’s Name Date of Birth Date
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: ______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Consultations to obtain:
_____________________________________________________________________________________________________________
Date: __________________ Doctor’s Signature: _______________________________________
3/19
LOMS / Card Oral and Maxillofacial Surgery Inc. 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:
Cash, Check, Visa®, MasterCard®, Discover Card®, or American Express®
Convenient Monthly Payment Options¹ from Care Credit Healthcare Credit Card
Allows you to pay over a period of time- No annual fees or pre-payment penalties
Leavenworth Oral and Maxillofacial Surgery require 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.
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. 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.
Patient Information
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) 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) 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
A Sterling Card DMD MD
Diplomate American Board of Oral & Maxillofacial Surgery
Informed Consent for CBCT
I HEREBY AUTHORIZE CARD ORAL AND MAXILLOFACIAL SURGERY INC. to perform a CBCT scan.
A CBCT scan is usually referred to as a Cone Beam Computerized Tomography. This is an x-ray technique similar to medical CT scan, The technique produces images of your body that depicts internal structures in cross sections rather than the over lapping images typically produced by conventional x-ray exams. Conventional x-rays limit your dentist ability to evaluate anatomical structures in a 2 dimensional view. Your diagnosis and treatment planning can be enhanced by a more complete understanding of complex 3 dimensional anatomies. The relationship of anatomical structures in 3D is important in assessing your condition as well as treatment planning for dental implants and\or surgical extractions. CT scans may be useful in evaluating and potentially diagnosing conditions which cannot be properly seen with conventional x-rays.
CBCT scans, like conventional CT scans, expose you to radiation. However, the dose from the CBCT scan is up to 80% less than traditional CT. CBCT scans are NOT recommended for pregnant women. Please check appropriate line.
_____I am not pregnant ____I am pregnant _____I am unsure whether I am pregnant
A CBCT scan is not a covered benefit with most insurance companies. The cost of a CBCT in our clinic is $359.00. This will be an out of pocket expense. As a courtesy to our patients we will file with all insurance companies. NOTE: A CBCT scan is REQUIRED for all Implant consultations and other consultations as deemed necessary by the doctor.
I give permission for Card OMS Inc. to take and share images with my referring Doctor(s).
Patient/Guardian Signature________________________________
Date_____________
(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 contact our 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. 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 protected health information. Marketing We may contact you to provide you with information about treatment alternatives, or with information about other health-related benefits and services that may be of interest to you. For Specialized Governmental Functions We may disclose your protected health information for specialized government functions as authorized by law, such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel. Other Uses Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided.
1. May we have your permission to leave voice and/or text messages regarding appointments or requests for your call backs? Yes___No___Cell phone/answering machine ( )____________
2. To whom may we release protected health information (PHI)?
____ To myself only
____ To myself and PCP Dr. ______________________
____ To myself and the following designated person(s)
Name_________________________ Relationship____________________
Name_________________________ Relationship____________________
Name_________________________ Relationship____________________
Assignment of Insurance Benefits Release of Medical Information
I understand pre-certifications/authorizations/referrals are my responsibility. I hereby consent to medical evaluations, testing, and/or treatment provided to me by (Leavenworth) Card Oral & Maxillofacial Surgery Inc. I understand that in order to carry out treatment, payment and other healthcare operations, Card Oral & Maxillofacial Surgery Inc. may use PHI. I authorize release of any information concerning me or my child’s health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I also hereby give lifetime authorization for payment of insurance benefits directly to Card Oral & Maxillofacial Surgery Inc. and agree to any remaining balance once my insurance plan has processed my claim. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default, I agree to pay all costs of collections and reasonable attorney fees.
I hereby acknowledge that I have received a copy of this practice’s Notice of Privacy Practices. I have been given the opportunity to ask any questions I may have regarding this Notice.
X_________________________________ ______________Card Oral & Maxillofacial Surgery Inc.
Name Date 3550 S 4th St Suite 240
8/14 Leavenworth, KS 66048
913.772.4334
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