DUNNING FAMILY DENTAL

191 Guy Pork AvenueAmsterdom, NY

,l20]0

s18-842-3220

reception @ rjd u n n i ngdds-pc, comPATIENT REGISTRATION FORM

INSTRUCTIONS TO PATIENT:

(PLEASE PRTNT)

Patient Name Soc. Sec, No, Home Telephone Work Telephone

Patient Address City/State Zip Code Date of Birlh

Marital Status

Single n Manied E Divorced n Widow EOccupation Sex

run FtrEmployer Name Employer Address Name of Spouse

Cell Phone E-mail

WHO IS RESPONSIBLE FOR THIS ACCOUNT IF OTHER THAN PATIENT?

Patient Name Soc, Sec. No, Home Telephone Work Telephone

Patient Address City/State Zip Code Date of Birth

Marital Status

Single n Married n Divorced fl Widow nOccupatlon Sex

MN FNEmployer Name Employer Address Cell Phone E-mail

DENTAL INSURANCE INFORMATION

Name ol Primary lns, Co. Policy No. Group Owner of Policy Soc. Sec. No. Date of Birth How are you related to the palienl?

Do You Have Other lns. (Name) Policy No, Group Owner ol Policy Soc. Sec. No. Date of Birth How are you related to the patient?

CONSENT:

The undersigned hereby authorizel)Doctor to take X-rays, study models, photographs, or any other diagnoslic aids deemed appropriate by doctor to make a thoroughdiagnosis ol the patient's dental needs. I also authorize Doctor to perlorm any and all forms of treatment, medical and therapy, that may be indicated, I also understandthe use of anesthetic agents embodies a certaln risk. I understand that responsibility lor payment for Dental Services provided in lhis olfice for myselt or my dependentsis mine, due and payable at the time services are rendered unless linancial arrangements have been made. I also assign all lnsurance benefits to the Doctor and realizethat I am responsible for any balance not paid by insurance. All fees incurred to enforce payment required by this agreement will be paid by the delinquent client whosefailure to pay required said costs to be incurred. Submission to treatment implies consent as oullined in this agreement.

Patient Signature (Parent of Child) Dale:

-

Dentist Signature

HEALTH HISTORY AND REGISTRATIONMEDICAL HISTORY

IT IS IMPOBTANT THAT WE KNOW YOUH MEDICAL AND DENTAL HISTOBY.THESE FACTS HAVE A DIBECT BEAHING ON YOUR DENTAL HEALTH AND TBEATMENT,THIS INFORMATION IS STRICTLY CONFIDENTIAL AND WILL NOT BE RELEASED,

DO YOU HAVE ANY CUBBENT HEALTH PBOBLEIMS?

IF YES, PLEASE EXPLAIN:

YES NO

ARE YOU PBEGNANT

DO YOU SIMOKE OR USE TOBACCO PFODUCTS?

ABE YOU TAKING ANY MEDICINES? .

IF YES, PLEASE LIST:

VtrQtLu_ NO_YES

YES

NO

NO

ARE YOU ALERGIC OR HAVE YOU HEACTED ADVERSELY TO ANY OF THE FOLLOWING

PENICILLINTETHACYCLINE

EHYTHROMYCIN

NOVOCAINE

MEDICATIONS?

IODINE AMOXICILLIN

CLOROX SULFA

ASPIHIN

CODEINE

MOTRIN

DARVON

ARE YOU AWARE OF ANYYOU ARE ALLERGIC TO?

IF YES, PLEASE EXPLAIN:

OTHER MEDICATIONS OB SUBSTANCESYES NO

CIBCLE ANY OF THE FOLLOWING YOU HAVE HAD OR HAVE AT PFESENT:

A.I,D.SAlcoholismAllergies or HivesAnemiaAngina PectorisArthritisArtiticial Heart ValveArtificial Joints (Hip, Knee)AsthmaBleeding ProblemsBlood TransfusionBruise EasilyChemotherapy (Cancer, Leukemia)

FAMILY PHYSICIAN

Cortisone MedicineCosmetic SurgeryDiabetesDialyslsDrug AddiclionEmphysomaEpilepsy or SeizuresFainting or Dizzy SpellsFever BlistersGlaucomaHay FeverHeart Disease or AtlackHeart Failure

Heart MurmurHeart PacemakerHoart SurgeryHemophiliaHepatitis A (infectious)Hepatitis B (serum)High Blood Pressurelrregular HeartbeatJaund iceKidney TroubleLiver DiseaseMitral Valve ProlapsePain in Jaw Joints

Psychiatric TreatmontBadiation TrealmentRheumatic FeverBheumatismScarlet FeverSinus TroubleStentStrokeThyroid DiseaseTuberculosis (TB)UlcersVenereal Disease (Syphilis,

Gonorrhea, etc.)

NOTIFY IN EMERGENCY

PHONE NO,

PHONE NO.

DENTAL HISTORYHOW LONG SINCE YOU HAVE SEEN A DENTIST?

APPROXIMATE DATE OF LAST FULL MOUTH X.RAYS?

ARE YOU HAVING A PHOBLEN/ NOW?

IF YES, PLEASE EXPLAIN:

YES

DO YOU WEAR DENTUBES? (FULL OR PAHTIAL)

HAVE YOU HAD PERIODONTAL THEATMENTS?

HAVE YOU HAD ORTHODONTIC TREATMENT?

ARE YOU AWARE OF GRINDING OB CLENCHING YOUR TEETH?

DO YOU HAVE HEADACHES, EARACHES, OB NECK PAINS?

DO YOUR GUMS BLEED, OR'FEEL TENDER OR IRRITATED?

DO YOU NOTICE ANY CLICKING OR POPPING IN OR AROUND YOUR EABS?

NO

YES

YES

YES

YES

YES

YES

YES

NO

NO

NO

NO

NO

NO

NO

IS THEBE ANY OTHER MEDICAL OR DENTAL INFORMATION THAT YOU FEEL I SHOULD KNOW ABOUT?

DUNNING FAMILY DENTAL191 Guy pork AvenueAmsterdom, Ny I 20.l O

518-842_3220

CONSENT FOR USE AND DISCLOSUREOF HEAHH INFORMATION

SECT]ON Ar PATIENT GIVING CONSENT

Name:

Addressl

Telephone: E'mailr

Patlent #: ,Sccial Security #r,

SECTION B: TO THE PATIENT - PLEASE READ THE FOLLOWING SIATEMENTS CAREFULLY

Putpose ol Consent: By slgnirrg ihis form, you wlll consent to our use and disclosure of your protected health lnfor.mation to carry out treatment, payment activities, and healthcare operations,

Nqtlce of Privacy Practlces: You have the right to read our Notice of Privacy Practices belore you declde whetherto slgn thls Consent, Our Notlce provides a descrlptlon ol ourtreatment, payment actlviiies, and healthcare oper.ations, of the uses and disclosures we may make of your protected health information, and of other lmportant mat.ters about your protected health information, A copy of our Notice accompanies this Consent, We encourage you toread lt carefully and completely before signing this Consent,

We reserve the rlght to change our prlvacy practices as described in our Notice of Prlvacy Practices. lf we changeourprivacy practices, we will lssue a revised Notice of Privacy Practices, which wlll contain the changes,Thosechanges may apply to any of your protected health inlormation that we maintain,

You may obtain a copy of our Notice of Privacy Practlces, lncludlng any revisions of our Notice, at any tlme by contactlng:

Contacl Person:

Telephone:

E.mail:

Rlghl to Revokel You wlll have the rlght to revoke ihls Consent at any time by givlng us written notice of yourrevocaiion submitted to the Contact Person listed above, Please understand that revocation of this Consent will notatfect any action we tcok in rellance on ihis Consent before v;e received your revocation, and that we may decline totreat you or to continue treating you if you revoke this Consent,

SIGNATURE

|..havehadfullopportunitytoreadandconsiderthecontents of thls Consent form and your Notice ol Privacy Pracl,lces, I understand that, by signing this Consentform, I am glvlng my consent to your use and dlsclosure of my protected health information to carry out treatment,payment activitles and health care operations,

Slonaturel

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

Personal Representatlve's Name:

Relationship to Patlentr

YOU ARE ENTITLED TO A COPY OF.THIS CONSENT AFTER YOU SIGN ITtncludE compleled Congent ln the pal'lent's charl.

REVOCATION OF CONSENT

I revoke my Consent for your use and disclosure of my protected healih informatiorr for treatment, paynrentactivities, and healthcare operations,

I understand that revocation of my Consent will not affect,an).actioh you took in:reliance on my Consent,before y6ureceived this written Notice of Revocation. l:also understand that you'may decline to treat or to continue to treat meaf ter I have revoked my Consent.

Srgnature: Date:

@ 2002 American Oental Associalion

All Rights ReseRed

Rep/oduction and use oflhis form by dentists and their staff ls permitted. Any other use. duplication ordistribution ol this form by anybther party requlres the prior

wriltep apprilval cif the AmErican Dentdl fusociation.

This Form is educational only, doei not constilut€ lsgal advlcs, and coveri only ledoral, hot state, law (August 14, 2002).

ACKNOWLEDGEMENT OF RECEIPT

I acknowledge that I have received a copy of DUNNING FAMILY DENTAL's Notice of Privacy Practices.

Patient Name

Signat u re Date

Effective date of notice:

NOTICE OF PRIVACY PRACTICES

Dunning Eamily DentaL19L Guy Park Ave

Amsterdam, New York t2ot0Phone (518) 842-3220Fax (518) 843-0830

E Mail receptionGrjdunningdds-pc. comContact, Francine Fura or Kathy Fura

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOUMAY BE USED AND DISCLOSED AIYD HOW YOU CA}I GET ACCESS TO

THIS INFORMATION. PLEASE REVIEW IT CAREF'ULLY.

We respect our legal obligation to keep health information that identifies you private. We are obligatedby law to give you notice of our privacy practices. This Notice describes how we protect your healthinformation and what rights you have regarding it.

TREATMENT, PAYMENT, AND HXALTH CARE OPERATIONSThe most corrunon reason why we use or disblose your health information is for treatment, payment or

health care operations. Examples of how we use or disclose information for treatment purposes are:setting up an appointment for you; examining your teeth, mouth, and oral health; prescribing medicationsand faxing them to be filled; prescribing dental appliances and dental prostheses; showing you treatmentoptions; referring you to another dentist for specialfy oare; or getting copies ofyour health informationfrom another professional that you may have seen before us, Examples of how we use or disclose yourhealth information for payment purposes are: asking you about your dental or medical care plans, or othersources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselvesorthrough a collection agency or attorney). "Health care operations" mean those administrative andmanagerial functions that we have to do in order to run our offrce. Examples of how we use or discloseyour health information for health care operations are: financial or billing audits; internal qualityassurance; personnel decisions; participation in managed care plans; defense oflegal matters; businessplanning; and outside storage of our records.

We routinely use your health information inside our offlce for these purposes without any specialpermission. If we need to disclose your health information outside of our offrce for these reasons[we usually will not] ask you for speoial written permission.

USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSIONIn some limited situations, the law allows or requires us to use or disclose your health information

withoutyourpermission. Notall ofthesesituationswillapplytous; somemaynevercomeupatourofflceat all, Such uses or disclosures are:

' when a state or federal law mandates that certain health information be reported for a specificpurpose;

' forlublic health purposes, such as contagious disease reporting, investigation or surveillance; andnotices to and from the federal Food and Drug Administration regarding drugs or medical devices;

. disclosures to govemmental authorities about victims of suspected abuse, neglect or domesticviolence;

. uses and disclosures for health oversight activities, such as for the licensing ofdoctors; for audits

by Medicare or Medicaid; or for investigation of possible violations of health care laws;

. disclosures forjudicial and administrative proceedings, such as in response to subpoenas or orders

of courts or administrative agencies:

. disclosures for law enforcement purposes, such as to provide information about someone who is or

is suspected to be a victim of a crime; to provide information about a crime at our ofEce; or toreport a crime that happened somewhere else;

. disclosure to a medical examiner to identifu a dead person or to determine the cause of death; or to

funeral directors to aid in burial; or to organizations that handle organ or tissue donations;

. uses or disclosures for health related research;

. uses and disclosures to prevent a serious threat to health or safety;

. uses or disclosures for specialized govemment functions, such as for the protection of the

president or high ranking govemment officials; for lawful national intelligence activities; formilitary purposes; or for the evaluation and health of members of the foreign service;

. disclosures of de-identified information;

' disclosures relating to worker's compensation programs;

disclosures ofa "limited data set" for research, public health, or health care operations;

incidental disclosures that are an unavoidable by-product ofpermitted uses or disclosures;

disclosures to "business associates" who perform health care operations for us and who commit torespect the privacy of your health information.

APPOINTMENT REMINDERSWe may call or write to remind you of scheduled appointments, or that it is time to make a routine

appointment. We may also call or write to notifu you of other treatments or services available at our officethat might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a postcard, and/or leave you a reminder message on your home answering machine or with someone whoanswers your phone if you are not home.

OTHER USES AND DISCLOSURESWe will not make any other uses or disclosures of your health information unless you sign a written

"authorization form." The content of an "authorization form" is determined by federal law. Sometimes, wemay initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate theprocess if it's your idea for us to send your information to someone else. Typically, in this situation youwill give us a properly completed authorization form, or you can use one of ours.

If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If youdo not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke itat any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them tothe office contact person named at the beginning of this Notice.

YOUR RIGHTS REGARDING YOUR HEARH INFORMATIONThe law gives you many rights regarding your health information. You can:

. ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment),payment or health care operations. We do not have to agree to do this, but if we agree, we musthonor the restrictions that you want. We must honor a restriction not to send information to ahealth care plan regarding any service for which you have already made full payment. To ask for a

restriction, send a written request to the office contact person at the address, fax or E Mail shown

at the beginning of this Notice.. ask us to communicate with you in a confidential way, such as by phoning you at work rather than

at home, by mailing health information to a different address, or by using E mail to your personalEMailaddress. Wewillaccommodatetheserequestsiftheyarereasonable,andifyoupayusforany extra cost. If you want to ask for confidential communications, send a written request to theoffice contact person at the address, fax or E mail shown at the beginning of this Notice.

. ask to see or to get photocopies of your health information. By law, there are a few limitedsituations in which we can refuse to permit access or copying. For the most part, however, youwill be able to review or have a copy of your health information within l0 days of asking us. Youmay have to pay for photocopies in advance. If we deny your request, we will send you a writtenexplanation, and instructions about how to get an impartial review of our denial if one is legallyavailable. If you want to review or get photocopies of your health information, send a writtenrequest to the office contact person at the address, fax or E mail shown at the beginning of thisNotice.

. ask us to amend your health information if you think that it is incorrect or incomplete. If we

agree, we will amend the information within 60 days from when you ask us. We will send the

corrected information to persons who we know got the wrong information, and others that youspecif,. If we do not agree, you can write a statement of your position, and we will include it withyour health information along with any rebuftal statement that we may write. Once your statementof position and/or our rebuttal is included in your health information, we will send it alongwhenever we make a permitted disclosure of your health information. By law, we can have one 30day extension of time to consider a request for amendment if we notifu you in writing of theextension. lf you want to ask us to amend your health information, send a written request,including your reasons for the amendment, to the office contact person at the address, fax or Email shown at the beginning of this Notice.

. get a lisi of the disclosures that we have made of your health information within the past six years

(or a shorter period if you want). By law, the list will not include: disclosures for purposes oftreatment, payment or health care operations; disclosures with your authorization; incidentaldisclosures; disclosures required by law; and some other limited disclosures. You are entitled toone such list per year without charge. If you want more frequent lists, you will have to pay forthem in advance. We will usually respond to your request within 60 days of receiving it, but bylaw we can have one 30 day extension of time if we notif, you of the extension in writing. If youwant a list, send a written request to the office contact person at the address, fax or E mail shownat the beginning of this Notice.

. get additional paper copies of this Notice of Privacy Practices upon request. It does not matterwhether you got one electronically or in paper form already. Ifyou want additional paper copies,send a written request to the office contact person at the address, fax or E mail shown at thebeginning of this Notice.

be notified by us in a timely manner of any breach of the privacy and confidentiality of your unsecuredprotected health information, wllich we will provide to you in accordance with law and take all appropriatemeasures to address.

OUR NOTICE OF PRIVACY PRACTICESBy law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it.

We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the newprivacy practices will apply to your health information that we already have as well as to such informationthat we may generate in the future. If we change our Notice of Privacy Practices, we will post the newnotice in our omce, have copies available in our offrce, iind post it on our Web site.

COMPLAINTSIf you think that we have not properly respected the privacy of your health information, you are free to

complain to us or the U.S. Department of Health and Human Services, Office for Civil Nghts. We will notretaliate against you if you make a complaint. If you want to complain to us, send a written complaint tothe office contact person at the address, fax or E mail shown at the beginning of this Notice. If you prefer,you can discuss your complaint in person or by phone.

FORMOREINFORIvTA*TIONIf you want more information about our privacy practices, call or visit the office contact person at the

address or phone number shown at the beginning of this Notice.