Dr.

Mr. Date

Mrs.

Miss Birthdate S.S.#Last First Middle

If Child,

Parent's Name Marital Status M/F

Home AddressStreet City State Zip

E-Mail Address Home Phone Cell Phone

Occupation Employer Work Phone

Who Will Be Responsible

For This Account? Relationship

• Do You Have Dental Insurance? Yes No

Primary Dental Insurance Company Name of Employee Carrying Ins.

Employee's 0.0.8. Employee's SS #

Name of Employer or Company Group #

• Secondary Dental Insurance Company Name of Employee Carrying Ins .

Employee's D.O.B. Employee's SS #

Name of Employer or Company Group #

MEDICAL HISTORY REFERRED BY

Check Conditions You Have Had:

-- Rheumatic Fever -- Arthritis -- Sinus Problems -- Venereal Disease -- Artificial Joints

__ Heart Murmur (MVP) __ Blood Trouble (Anemia) __ Asthma, T.B., Emphysema -- Cancer -- Pacemakers

-- Heart Trouble __ Diabetes (Insulin?) __ Excessive Bleeding -- Radiation Treatment __ Thyroid Disorder

__ High Blood Pressure __ Kidney Disease __ Psychotherapy (Nervous Breakdown) -- HIV + Are you taking Fosamax? OY ON

-- Stroke __ Hepatitis __ Fainting Spells __ Convulsions (Epilepsy)

Allergic to Medications? (Which?)

Medications you are Currently Taking:

Pregnant? How Many Months?-

Physician's Name Phone #

In Case of Emergency, Whom Should We Notify? Phone #

DENTAL HISTORY

Reason For Visit? What would you like to change about your teeth/smile?

How Long Since Last Exam/Treatment? Would you be interested in a mouthwash that eliminates bad breath? If so, Ask about BREATH Rx MOUTH RINSE.

Y N Have you ever had Periodontal Treatment or Surgery? Y N Are you interested in Cosmetic Dentistry?

Y N Do your gums bleed or feel tender? Y N Would you like whiter teeth?

Y N Are you dissatisfied with your teeth or their appearance?

Payment is expected when services are performed. We do not bill for services. If you have insurance, you are required to pay your estimated portion not covered by your insurance

the day of your appointment! We will gladly file your insurance as a courtesy to you. It is your responsibility to see that they pay on time. Initials

I understand that a charge may be added to my Account if a 4B hour notice isn't given when I am unable to keep an appointment. Initials

I, the undersigned, certify that the above information is correct to the best of my knowledge. I also agree that in the event of default in the payment of any amount due, and if this

account is placed in the hands of an agency or attorney for collection or legal action, to pay an additional charge equal to the cost of collection including agency and attorney fees and

court costs incurred and permitted by laws governing these transactions. I also understand that an 1B% interest charge will be placed on all outstanding balances over 90 days past

due.

Patient's Signature Parent's Signature (If under 1B years Old) Date

FOAM 005219 R/l1107 ITEM 8101

----------------------------------------------

~

Steineker IDillonFAMILY & COSMETIC DENTISTRY

CONSENT FOR USE AND DISCLOSUREOF HEALTH INFORMATION

SECTION A: PATIENT GIVING CONSENT

Name: _

Address: _

Telephone: Email: _

Patient #: ·_Social Security #: _

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

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health infor-mation to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Privacy Practices before you decide whetherto sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcareoperations, of the uses and disclosures we may make of your protected health information, and of other importantmatters about your protected health information. A copy of our Notice accompanies the Consent. We encourageyou to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we changeour privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Thosechanges may apply to any of your protected health information that we maintain.

Youmay obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:

Contact Person: Cindy McQueen

Telephone: 334-277-5665 Fax: 334-270-8923----------------------------Email: _

Address: 4730 Woodmere Blvd., Montgomery, AL 36106Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of yourrevocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will notaffect any action we took in reliance on this Consent before we received revocation, and that we may decline to treatyou or to continue treating you if you revoke this Consent.

SIGNATURE

I, , have had full opportunity to read and consider thecontents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consentform, I am giving my consent to your use and disclosure of my protected health information to carry out treatment,payment activities, and healthcare operations.

Signature: Date: _

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

Personal Representative's Name: _

Relationship to Patient: _

YOU ARE ENTITLED TO A COpy OF THIS CONSENT AFTER YOU SIGN IT.Include completed Consent in the patient's chart.

FORM 137900 NI02/09 rrEM 8101

REVOCATION OF CONSENT

I revoke my Consent for your use and disclosure of my protected health information for treatment, paymentactivities, and health care operations.

I understand that revocation of my Consent will not affect any action you took in reliance on my Consent before youreceived this written Notice of Revocation. I also understand that you may decline to treat or to continue to treat meafter I have revoked my Consent.

Signature: Date: _

© 2002 American Dental Association

All Rights Reserved

Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by other party requires the priorwritten approval of the American Dental Association.

This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).

Steineker & Dillon, P.C.

NOTICE OF PRIVACY PRACTICESTHIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND

DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTYWe are required by applicable federal and state law to maintain the privacy of your health information, We are alsorequired to give you this Notice about our privacy practices, our legal duties, and your rights concerning your healthinformation. We must follow the privacy practices that are described in this Notice while it is in effect. This Noticetakes effect , and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided suchchanges are permitted by applicable law. We reserve the right to make the changes in our privacy practices and thenew terms of our Notice effective for all health information that we maintain, including health information we creat·ed or received before we made the changes. Before we make a significant change in our privacy practices, we willchange this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for addition-al copies of this Notice, please contact us using the information listed at the end of this Notice,

USES AND DISCLOSURES OF HEALTH INFORMATIONWe use and disclose health information about you for treatment. payment. and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider pro-viding treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare oper-ations. Healthcare operations include quality assessment and improvement activities, reviewing the competence orqualifications of healthcare professionals, evaluating practitioner and provider performance, conducting trainingprograms, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment. payment or healthcare opera-tions, you may give us written authorization to use your health information or to disclose it to anyone for any pur-pose, If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any useor disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, wecannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the PatientRights section of this Notice. We may disclose your health information to a family member, friend or other personto the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree thatwe may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of(including identifying or locating) a family member, your personal representative or another person responsible foryour care, of your location, your general condition, or death. If you are present. then prior to use or disclosure of yourhealth information, we will provide you with an opportunity to object to such uses or disclosures. In the event of yourincapacity or emergency circumstances, we will disclose health information based on a determination using ourprofessionaljudgment disclosing only health information that is directly relevant to the person's involvement in yourhealthcare. We will also use our professionaljudgment and our experience with common practice to make reason-able inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, orother similar forms of health information.

Marketing Health·Related Services: We will not use your health information for marketing communicationswithout your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law,

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe thatyou are a possible victim of abuse, neglect. or domestic violence or the possible victim of other crimes, We may dis-close your health information to the extent necessary to avert a serious threat to your health or safety or the healthor safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel undercertain circumstances. We may disclose to authorized federal officials health information required for lawful Intelll-gence, counterintelligence, and other national security activities. We may disclose to correctional institution or lawenforcement official having lawful custody of protected health information of inmate or patient under certain circum-stances.

Appointment Reminders: We may use or disclose your health information to provide you with appointmentreminders (such as voicemail messages, postcards, or letters).

PATIENT RIGHTSAccess: You have the right to look at or get copies of your health information, with limited exceptions. You mayrequest that we provide copies in a format other than photocopies. We will use the format you request unless wecannot practicably do so. (You must make a request in writing to obtain access to your health information. You mayobtain a form to request access by using the contact information listed at the end of this Notice. We will charge youa reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending usa letter to the address at the end of this Notice. If you request copies, we will charge you $O. for each page,$ per hour for staff time to locate and copy your health information, and postage if you want the copies mailedto you. If you request an alternative format. we will charge a cost-based fee for providing your health information inthat format. If you prefer, We will prepare a summary or an explanation of your health information for a fee. Contactus using the information listed at the end of this Notice for a full explanation of our fee structure.)

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates·disclosed your health information for purposes, other than treatment. payment healthcare operations and certainother activities, for the last 6 years, but not before Apri I 14, 2003. If you request this accounting more than once in a12·month period. we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of yourhealth information. We are not required to agree to these additional restrictions, but if we do, we will abide by ouragreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your health Intor-mation by alternative means or to alternative locations. (You must make your request in writing.) Your request mustspecify the alternative means or location, and provide satisfactory explanation how payments will be handled underthe alternative means or location you request.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing,and it must expla in why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-rnail). you are entitled toreceive this Notice in written form.

QUESTIONS AND COMPLAINTSIf you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made aboutaccess to your health information or in response to a request you made to amend or restrict the use or disclosure ofyour health information or to have us communicate with you by alternative means or at alternative locations, youmay complain to us using the contact information listed at the end of this Notice. You also may submit a writtencomplaint to the U.5. Department of Health and Human Services. We will provide you with the address to file yourcomplaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to filea complaint with us or with the U.S. Department of Health and Human Services.

Contact Officer: Cindy McQueen

Telephone: _3_3_4_-2_7_7_-_5_6_65 Fax: 334-270-8923

E·mail: _

Address: 4730 Woodmere Blvd., MontQomery, AL 36106

o 2002 American Dental Association

All Rights Reserved

Reproduction and use of this form by dentists and their staff is permitted. Any other use. duplication or distribution of this form by any other party requires the priorwritten approval of the American Dental Association.

This Form Is educatIOnal only, does not constitute Ieg8ladYlce, and covers only federal, not state, law (August 14,2002).

Steineker & Dillon, P.C.

ACKNOWLEDGEMENT OF RECEIPT OFNOTICE OF PRIVACY PRACTICES

* YouMay Refuse to Sign This Acknowedgement*

I,office's Notice of Privacy Practices.

__________________________ , have received a copy of this

Please Print Name

Signature

Date

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, butacknowledgement could not be obtained because:

D Individual refused to sign

D Communications barriers prohibited obtaining the acknowledgement

D An emergency situation prevented us from obtaining acknowledgement

D Other (Please Specify)

.£ 2002 American Dental Association

All Rights Reserved

Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the priorwritten approval of the American Dental Association

This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).