7103 W. G RANDRID GE BLVD ., SUITE G . KENN EWICK, WA 99336

PHONE ' 509.737.1800

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Patient Name: _____ ______________ ___________

Patient DOB: ______________________________

55#: _ _______________________________________________________

Address: _________________________________

City: ____________________ 5tate: ____ Zip: __________

HomePhone: ______________________________

WorkPhone: _______ _ _ _______________________

Cell Phone: __________________________________

Drivers License #: ________________________________

5tatus: 05ingle 0 Married 0 Divorced o Widowed

Email Address: _____________________________________

Responsible Party Name: ___________________________

Address (if different than above): _________________________

Responsible Party DOB: ______ ______ _ _________________

55#: ________________ _ _________________________________________

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Primary Insurance Co:

Insurance Co. Phone #:

Employer:

Insured Employee Name:

Insured Employee DOB:

55 #/5ubscriber #:

5econdary Insurance Co:

Insurance Co. Phone #:

Employer:

Insured Employee Name:

Insured Employee DOB:

55 #/5ubscriber #:

Referred to us by? or, How did you hear about Grandridge Dental?______________=> o >­

o ~ Hobbies/lnterests: ____________ ___________________

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Is a member of your family a patient in our office? yes D no Do I- Their Name: ___________ ----___________ ____ ____--­~ Z Address: ____ _____________________________ l­

City: _______________ State: ____ Zip: ___________I­w ~

Name of Individual you would like us to contact in an emergency: _ ______________ U I­

« Address: ________________________________________ I­Z City: ________________ State: ____ Zip: ____________ o U Home Phone: ___________ Work Phone: ___________ Ext.# _____

>­U Z Closest Relative NOT Living With You: _________________________w ~ Address: __--________________________________a:: w

City: _ _______________ State: ____ Zip: ___________ ~ w

Home Phone: ______ ______Work Phone: ___________ Ext.# _____

Please Read: Office Policies & Federal Truth-in-Lending Statement: As a condition of your treatment by this office, financial arrangements must be made in advance. Patient co-payments (the amount not covered by insurance) are due and payable at the time of service. There will be a fee assessed for missed appointments.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for at the time services are rendered .

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the insurance forms of our patients or assist in making col'lections from insurance companies and will credit any such collections received to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid in full by an insurance company.

A service charge of 1.5% per month (18% per annum) on the unpaid balance will be assessed on all accounts exceeding sixty days from the date of service. Fee estimates for dental care can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me, or at my request for my minor child or ward by the dentist, I agree to pay, the reasonable value of said services to said dentist or his assignee at the time said services are rendered, or within thirty (30) days of billing if credit shall be extended, I further agree that the reasonable values of said services shall be as billed unless objected to by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any term of condition hereunder shall not constitute a waiver of any further term or condition, and I further agree to pay all costs and reasonable attorney fees if suit is instituted hereunder to collect monies owed by me, including interest charges, processing fees or commissions (up to 50% ofprinciple) that may be assessed by any collection agency retained to pursue this matter.

I grant my permission to you or your assignee to telephone me at home or at my workplace to discuss matters relating to this form.

I authorize assignment or payment of all dental and/or surgical benefits to which I or other family members are entitled, including private dental insurance or other group health plan benefits otherwise payable to the undersigned, to Dr. Jeffrey Morgan.

I certify that I have answered all questions on the form accurately and I hereby agree to abide by the conditions outlined there in.

Signature of Patient, Parent or Guardian Date Relationship to Patient

Patient Name:

7103 W. GRANDRlDGE BLVD., SUITE G . KENNEWICK, WA 99336

PHONE' 509.737.1800

~ase read, and answer the following questions: Medical History Form

Yes No o o 1. Are you having pain or discomfort at this time?

o o 2. Do you feel nervous about having dental treatment?

o o 3. Have you been hospitalized during the past two years?

o o 4. Have you been under the care of a medical doctor during the past two years? Physician's Name: _________ __________________

Type of Practice: ____________ Phone: ____________ Address: _______________________________

o o 5. Have you taken any medication or drugs during the past two years?

o o Are you now taking any medication, drugs or pills? If yes, please list: _________

0 o 6. Are you allergic or have you reacted adversely to any of the following medications? o Aspirin 0 NitroLls Oxide 0 Valium 0 Local Anesthetic o Darvon 0 Erythromycin 0 Scopolamine 0 (Novocaine or Xylocaine) o Codeine 0 Tetracycline 0 Penicillin 0 Sleeping Pills o Demerol 0 Percodan 0 other antibiotics 0 (Nembutal/Seconal)

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7. Check any of the following, which you have had or have at present: o Heart Failure o Heart Disease or Attack o Angina Pectoris o High Blood Pressure o Heart Murmur o Rheumatic Fever o Congenital Heart Lesions o Scarlet Fever o Heart Pacemaker o Heart Surgery o Artificial Joints (Hip, Knee) o Anemia o Stroke o KidneyTrouble o Ulcers o Cosmetic Surgery o Drug Addiction

0 Emphysema 0 Cough 0 Tuberculosis (TB) 0 Asthma o Hay Fever o Sinus Trouble 0 Allergies or Hives 0 Diabetes D ThyrOid 0 X-ray or COBALT Treatment

o A.I.D.S. or H.I.V. o Hepatitus A (infectious) o Hepatitus B (serum) o Hepatitus C o Liver Disease o Yellow Jaundice 0 Blood Transfusion 0 Hemophilia 0 Fever Blisters 0 Epilepsy or Seisures

0 Chemotherapy (Cancer, Leukemia) 0 Fainting/Dizzy Spells 0 Arthritis 0 Nervousness 0 Rheumatism 0 Psychiatric Treatment 0 Cortisone Medicine 0 Sickle Cell Disease 0 Glaucoma 0 Bruise Easily 0 Pain in Jaw Joints 0 Other _________ 0 Cold Sores 0 Other _________

o 0 8. When you walk up stairs or take a walk, do you have to stop because of pain in chest, shortness of breath, or beca use you are very ti red?

o 0 9. Do your ankles swell during the day? o 0 10. Do you use more than 2 pillows to sleep? o 0 11. Are you on a special diet? If so, explain _______________________

o 0 12. Do you have any disease, condition, or problem not listed? ________________ o 0 13. Have you visited a dentist in the past year? Date of last denta ll visit _____________ FOR WOMEN ONLY: Are you pregnant? If yes, what month _ _______________

o 0 Are you taking birth control pills?

Signature ofPatient, Parent or Guardian Date Relationship to Patient

I hereby certify that the answers to the above questions are accurate to the best of my knowledge.

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I have reviewed the foregoing Medical History (other side) and find it to be unchanged and accurate, except as noted.

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Signature ofPatient, Parent or Guardian

Signature ofPatient, Parent or Guardian

Date

Date

Update

Update

Signature ofPatient, Parent or Guardian Date Update

Health Questionnaire &Acknowledgement with Consent to Proceed

< w 0:: I certify that the answers to the health questions are accurate and correct to the best of my knowledge. Since a change w of medical condition or medications can affect dental treatment, I understand the importance of and agree to notify ~ the dentist of any changes at any changes at any subsequent appointment. w ~ I authorize Dr. Jeffrey Morgan and/or such associates or assistants as he may designate, to perform those procedures

as may be deemed necessary or advisable to maintain my dental health or the dental health of any minor or other individual for which I have responsibility, including arrangement and/or administration of any sedative (including nitrous oxide), analgesic, other pharmaceutical agent(s), including those related to restorative palliative, therapeutic or

surgical treatments.

I understand that the administration of local anesthetic may cause an untoward reaction or side effects which may include but are not limited to, bruising, hematoma, cardiac stimulation, temporary or permanent numbness, and muscle soreness.

I do voluntarily assume any and all possible risks, including the risk of substantial and serious harm, if any, which may be associated with general preventative and operative treatment procedures in hopes of obtaining the potential desired results, which mayor may not be achieved, for my benefit or the benefit of my minor child or ward. I acknowledge that the nature and purpose of the foregoing procedures have been explained to me as necessary and I have been given the opportunity to ask questions.

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Mediation &Arbitration Agreement

Any claim or controversy between the patient and/or a legally authorized representative of the patient and dentist concerning the care and treatment or the quality of dental services rendered by the dentist to the patient shall be resolved by mediation or arbitration according to the rules of the arbitration service. A claim or controversy shall first be submitted to non-binding mediation. If the claim or controversy is not resolved to the satisfaction of both parties through the mediation process, it will be submitted to binding arbitration.

Judgement(s) on the decision achieved through mediation or rendered by the arbitrator(s) can be entered in any court having jurisdiction thereof. Costs for mediation and/or arbitration services shall be shared equally by the parties involved. The foregoing mediation/arbitration agreement does not pertain to actions taken for the collection of debts owed as a result of dental services rendered.

Signature ofPatient, Parent or Guardian Date Relationship to Patient

Signature ofWitness Date

HIPAA Notice of Privacy Practices

GRANDRIDGE DENTAL 7103 Grandridge Blvd. , Suite G

Kennewick, W A 99336 509-737 -1800

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.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law . It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

1. Uses and Disclosures of Protected Health Information

Uses and Disclosures of Protected Health Information Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician's practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students , licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases : Health Oversight: Abuse or Neglect: Food and Drug Administration requirements : Legal Proceedings: Law Enforcement: Coroners , Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers' Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other Permitted and Required Uses and Disclosures Will Be Made Only With Your Consent, Authorization or Opportunity to Object unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician'S practice has taken an action in reliance on the use or disclosure indicated in the authorization.

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Your Rights Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of vour protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is 110t required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information wi ll not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have cthe right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if anY, ,=of your protected health information.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

This notice was published and becomes effective on/or before April 14, 2003.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and

privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:

Print Name: S ignature______________ Date______