Novi Dentist

CONFIDENTIAL INFORMATION QUESTIONNAIRE

Patient Information * Required

Insurance and Financial Information * Required

ASSIGNMENT & RELEASE: Please sign below

I hereby authorize my insurance benefits to be paid directly to the dentists. I am financially responsible for any balances due and authorize the dentists to release any information for this claim. I authorized that my records can be used by the doctor if he so determines. In consideration of the services rendered to me by this dental office I am obligated to pay aid office in accordance with its credit terms and policy. I consent to the making of videotapes, photographs, and x-rays before, during, and after treatment, and to the use of same by the doctor in scientific papers or demonstrations. I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved.

Patient Medical and Dental History * Required

Do you have or have you had any of the following? * Required

Do you have or have you had any of the following? * Required

Are you allergic to or have you had any reaction to the following: * Required

Are you allergic to or have you had any reaction to the following: * Required

Women Only: * Required

Patient Dental History * Required

Diagnosis: Five Key Questions * Required

  • Possible constricted chewing envelope
  • Note: Small piece not wad
  • Possible dysfunction
  • Note: Substitute dry chewy food
  • Ask wear/ shorter or thinner
  • Looseness / mobility
  • Open spaces
  • Indicates problem active not adapted
  • Possible dysfunction
  • Consider sleep bruxism

Effective April 14, 2003, the new federal law known as the Health Insurance Portability and Accountability Act of 1996 ("HIP AA") requires this office to comply with certain rules regarding the maintenance of the privacy of your information that we have collected and will collect in the future. To comply with one of HIP AA's requirements, we are giving you a copy of our Notice of Privacy Practices. This Notice of Privacy Practices contains the information that HIP AA requires us to disclose regarding our privacy practices. Existing Michigan Law requires (in addition to our attempt to obtain your written acknowledgement, discussed above) us to obtain your written consent prior to disclosing any of your information except for our disclosures in connection with: a defense to a claim challenging our professional competence; a review entity's functions; a claim for a payment of fees; a third party payer's examination of our records; a court order as part of a criminal investigation; an identification of a dead body; a licensure investigation; or a child abuse/neglect investigation. From time to time it may be necessary for us to make disclosures of your information in connection with your treatment. For example, we may make a referral to or consult with another dentist or other health care professional, provide a specimen to a laboratory for testing or otherwise make disclosure of your information in connection with providing or coordinating your treatment.

Patient Acknowledgement * Required

Please sign this form below under the heading "acknowledgement" to acknowledge that you have today received a copy of our notice of privacy practices.

Consent * Required

Please sign this form below under the heading "Consent" to consent to our disclosure of your information that we deem necessmy in order to provide you with proper treatment.

Complete * Required