NOMBRE DEL PACIENTE Appellido Nombre M. Fecha de Nacimeinto: EDAD CORREO ELECTRONICO TELEFONO CASA: CELL: TRABAJO: DIRECCION

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1 APPT TIME ASSISTANT LDV NEW PATIENT / EXISITING PATIENT CHART # NOMBRE DEL PACIENTE Appellido Nombre M Fecha de Nacimeinto: EDAD CORREO ELECTRONICO TELEFONO CASA: CELL: TRABAJO: DIRECCION Calle Fecha de la ultima visita dental Motivo de la visita Su nino ha tenido algunas de estas condiciones medicas? Por favor marque SI o NO: SI NO SIDA SI NO Epilepsia SI NO SI NO Alergias SI NO Sangrado excesivo SI NO # Apartamento Cuidad Estado Codigo Postal HISTORIA MEDICA DEL PACIENTE SEXO Masculino Femenia Enfermedades del Rinon SI NO Problemas Estomacales Enfermedades del Higado SI NO Embolia SI NO Desmayos SI NO Desordenes Mentales SI NO Tuberculosis SI NO Glaucoma SI NO Desorden Nervioso SI NO Tumores SI NO Anemia SI NO Erupciones SI NO Marcapaso SI NO Ulceras SI NO Artritis SI NO Fiebre del Heno SI NO Embarazo SI NO Enfermedades Venereas SI NO Articulaciones artificiales SI NO Accidentes en la cabeza Fecha de T: SI NO Alergico a la Codeina SI NO Asma SI NO Enfermedades del corazon SI NO Tratmiento de Radiaciones SI NO Alergico a la Penicilina SI NO Enfermedades de la sangre SI NO Soplo en la corazon SI NO Problemas Respiratorios SI NO Otros: SI NO Cancer SI NO Hepatitis SI NO Fiebre Reumatica SI NO Diabetes SI NO Alta Presion SI NO Reumatismo SI NO Mareos SI NO Icterica SI NO Problema Sinisitis Ha tenido su nino alguna complicacion en tratmentios dentales? Si lo ha tenido, por favor expliquelo Su nino ha estado hospitalizado; o en la sala de emergencia los ultimos 2 anos? Si lo ha tenido, por favor expliquelo SI NO SI NO Nombre del Pediatra de su nino Telephono: Su nino esta siendo atendido por algun otro Doctor? SI NO Si lo tiene; Por favor mencionelo Tiene su nino alguna enfermedad importante que debamos saber? SI NO Si lo tiene; Por favor expliquelo Se me han informado todos los procedimientos; y las respuestas e informacion requerida es la correcta. Si existe algun cambio en la salud del paciente se informara inmediatamente. Firma del Padre/Guardian Fecha Como escucho de nuestra oficina? Por otro paciente, amigo Por otro paciente, pariente Otros Oficina Dental Nombre Paginas Amarillas Radio Internet Face book Television ppeliculas Television y Peliculas FOR OFFICE USE ONLY Weight: BP: / Pulse: Mission: Next Visit Exit Time Dr Reviewing Medical HX

2 INFORMACION DEL PADRE/GUARDIAN Nombre Masculino Femenino Casado Soltero Otro Fecha de Nacimeinto: # del Seguro Social Telephono CASA: TRABAJO: Ext. CELL Dirrecion Calle # de Apartamento Cuidad Estado Codigo Postal Nombre de Empleador Ocupacion Persona en caso de emergencia Relacion con el paciente Telephone de persona de emergencia # (CASA) (TRABAJO) Primary INFORMACION DEL SEGURO Nombre del asegurado SSN# Appellido Nombre MI Fecha de Nacimiento del asegurado ID # Group # Direccion del asegurado Calle Cuidad Estado Codigo Postal Nombre del empleador del asegurado Direccion Relacion del paciente con el asegurado Yo Esposo/a Hijo/a Otro Dir. Y Nombre de la aseguradora CONSENTIMIENTO DE SERVICIOS Una condicion para recibir tratamiento por esta oficina es hacer arreglos financieros con anticipacion. El consultorio depende sobre los reembolsos de costos de los pacientes que se agregaran a los tratamientos hechos en la oficina y es responsabilidad de cada paciente hacer el pago antes del tratamiento. Todos los servicios de emergencia dental que se realize sin una cita tendran que pagar en efective y antes de realizar el tratamiento. Pacientes con seguro dental entienden que los servicios dentales y tratamientos seran cargados directamente al paciente o a la persona responsable. Esta oficina ayuda a los pacientes a preparar formas del seguro del paciente o asistir a colectar de la compania de seguros el pago y hacerlo; y si el credito llega a sobrar se depositara a la cuenta del paciente directamente. Sin embargo la oficina no puede dar servicio y asumir los cargos que van a ser pagados por la compania de seguros. Un balance que no se ha pagado en mas de 60 dias se hara un cargo de 1 1/2 % por mes (18% anual). A menos que se haga un arreglo financiero satisfactorio. Entiendo que los honorarios calculados por el tratamiento solo son validos por us periodo de 6 meses a partir de la fecha de la examinacion del paciente. En consideracion con los servicios profesionales prestados que me son solicitados por el Doctor; por lo tanto estoy de acuerdo a pagar el valor del tratamiento que indique el Doctor o el asignee en el tiempo prestado al servicio. Ademas estoy de acuerdo en aceptar el valr que eligan por los servicios que pagare a menos que tuviera una objesion por mi. He leido las condiciones y pagos del tratamiento y estoy de acuerdo con en contenido. Yo doy mi consentimiento por mi nino/a, para que se haga un examen dental, radiografias dentales, y una limpieza de los dientes. Firma De Pariente/Guardian Relacion al Paciente Fecha

3 1. What does HIPPA stand for? HIPPA is an acronym for Health Insurance Portability & Accountability Act which was passed by Congress in Why should I sign now? Signing now simply lets us know you received the HIPPA Notice Practice. Of course you can choose not to sign. 3. What happens if I don t sign this acknowledgement form? First, you need to know we will provide you timely care and treatment whether or not you sign form. Second, if you choose not to sign the form, we will note your choice in the bottom of the acknowledgment form and hope you take a copy of the Notice. 4.Is my signature just acknowledging receipt of this notice? Yes. By signing this acknowledgment form we then can shoe the Department of Health & Human Services that we are complying with one of the major rules of HIPPA to make sure we give every patient the opportunity to have the Notice. You may refuse to sign this form! 5. Why is this notice so long compared to the ones I received from my financial institution or my credit card company of my life insurance company? Those companies are subject to a different set of private rules under the Graham/Leach Act while a;; healthcare organization are subject to HIPPA and (where indicated)state laws. 6. Are you doing anything different with my health information now than you did before HIPPA? Actually, we are going to guard you medical information even more closely. We have developed policies and procedures for our staff throughout (Little Heroes Pediatric Dentistry PLL)to follow to make certain your medical (dental) information is shared only with those needing your information for treatment, payment,or healthcare operations. 7. Is this HIPPA Notice and acknowledgment form only for Little Heroes Pediatric Dentistry PLL? Yes; however, all healthcare organizations such as hospitals, physicians offices, outpatient surgery centers, and home care or hospice are services are subject to HIPPA effective April 14, These other organizations will have their own Notice and acknowledgment form you will need to sign when you receive services from them. 8. After I sign this acknowledgment for, then what happens? We will place you form in your medical records and note your choice in our cimouter system once our new patient care information system is installed throughout out system later this year. In the meantime, when you return for the same type of service or another service here at Little Heroes Pediatric Dentistry we will need to ask you if you have received our HIPPA Privacy Notice. Since you have received one today you just need to let us know then that you already have one. 9. What am I going to be paying out because of signing? Signing our HIPPA Privacy Notice acknowledgment form has NO bearing on your current payment arrangements. 10. Am I expected to sign this acknowledgement form without reading the Privacy Notice? Yes. You are simply going on record that you have the Privacy Notice which we are required by the law that is the Health Insurance Portability & Accountability Act, to provide. Your signature does not indicate that you have read the Notice and agree with everything that is in it.

4 Acknowledgment of Receipt of Notice of Privacy Practices I acknowledge that I have been provided the opportunity to read a copy of Legacy Dental Notice of Privacy Practices. Patients Name: Date of Birth: Parents/Guardian Signature: Date: Clinical information will not be provided to anyone other than to you Legacy Dental as noted in the Notice of Privacy Practices. If you would like us to inform family members or other persons, if any, about your general medical condition and/ or your diagnosis (including treatment, payment and health care operations), please list those individuals here:. FOR OFFICE USE ONLY: We have made every effort to obtain written acknowledge of receipt of out Notice of Privacy from this patient but it could not be obtained because: Individual refuse to sign Due to an emergency situation it was not possible to obtain an acknowledgment A communication barrier prevented ECT from obtaining acknowledgment Other: (please provide specific details) Employee Signature: Date:

5 ACKNOWLEDGEMENT AND CONSENT BY PARENT/GUARDIAN TO TRANSFER AUTHORITY FOR TREATMENT I, certify that I am the parent and/or guardian of the following Parent/Guardian s Name child: ( the Patient ). I hereby give permission to request and Child s name authorize the following person(s): Name Relation to patient to transport the patient to/from Little Heroes Pediatric Dentistry dental office for examination and treatment; to accompany the patient while at Little Heroes Dentistry and to make any and all additional decisions as needed regarding consent for the patient s treatment. I designate and formally recognize the named person(s) that stand in for me as the parent/guardian of the patient at my request, are/is involved in the patient s care and treatment, and can receive the patient s health information and records, including any privileged or confidential information. I have already been advised of the necessary examination and treatment for the patient. I have received sufficient consent information explaining diagnosis, purpose of the procedures, material risks, benefits, alternatives, likelihood of success, and prognosis if rejected. I hereby request, consent to and authorize Little Heroes Pediatric Dentistry to provide such examination and treatment to the patient, including treatment of conditions which arise during such examination and treatment. However, to the extent additional consent is later requested, I authorize Little Heroes Pediatric Dentistry to rely upon the above-listed Person(s) to make any and all decisions and sign forms regarding the patient. I understand Little Heroes Pediatric Dentistry will not be held legally liable for any treatment changes or decisions made by the above listed Person(s), and that I will be liable for costs of the patient s care consented to by the Person(s) but not covered by Medicaid or Insurance. I have been advised by Little Heroes Pediatric Dentistry that it is in the patient s best interest for the patient s parents to be present; however, I have opted to delegate my decision making authority to the person(s) listed above; who will accompany the patient and act on the Patient s behalf at my request. This form is valid from the date signed, and a copy is as valid as the original. Signature of Parent or Guardian Name of Patient Date Date of Birth Little Heroes Pediatric Staff Witness

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