Patient Form

    Fill this out ONLY if you are not the Responsible Party for the Insurance Policy:

    Pharmacy Information

    Patient Information

    For the following questions, circle yes or no, whichever applies. Your answers are for our records only and will be kept confidential.

    1. Are you in good health?

    2. Has there been any change in your health in the past year?

    4. Are you now under the care of a physician?

    If so, for what condition?

    6. Have you had any serious illness, operation or hospitalization within the past 5 years?

    7. Have you had an artificial joint replacement (knee, hip, shoulder, etc.)?

    8. Are you taking or have you ever taken Bisphosphonates for osteoporosis or chemotherapy for multiple myeloma or other cancers (Reclast, Fosamax, Actonel, Boniva, Acedia or Zometa)?

    9. Are you taking any medicine(s) including diet pills, non-prescription, vitamins Homeopathic or natural remedies?

    a. Damaged heart valves, artificial valves or heart murmur

    b. Rheumatic Heart Disease

    c. Heart trouble, heart attack, angina, high blood pressure, stroke, arteriosclerosis or any other heart condition

    1. Chest pain upon exertion?

    2. Shortness of breath after mild exercise?

    3.Do your ankles swell?

    d. Allergies

    e. Sinus trouble

    f. Asthma or hay fever

    g. Fainting spells or seizures

    h. Diabetes

    i. Hepatitis, jaundice or liver disease

    j. Frequent or recurring mouth sores

    k. Thyroid problems

    l. Respiratory problems, emphysema, bronchitis, etc.

    m. Arthritis or painful, swollen joints including jaw joint (TMJ)

    n. Osteoporosis

    o. Stomach ulcer or hyperacidity

    p. Kidney trouble

    q. Tuberculosis

    r. Persistent cough or cough that produces blood

    s. Persistent swollen neck glands

    t. Low blood pressure

    u. Epilepsy or neurological disorder

    v. Cancer

    w. Any disease, drug or transplant operation that has depressed your immune system

    11. Have you had abnormal bleeding?

    a. Have you ever required a blood transfusion?

    12. Do you have any blood disorder such as anemia?

    13. Have you ever had treatment for a tumor or growth?

    14. Have you had radiation therapy to the head, neck or jaws?

    a. Local anesthetics

    b. Penicillin or antibiotics

    C. Sulfa drugs

    d. Barbiturates or sleeping pills

    e. Aspirin

    f. Iodine

    g. Codeine or other narcotics

    h. Latex or rubber products

    i. Other

    16. Have you had any serious trouble associated with previous dental treatment?

    17. Do you have any other condition or disease you think the doctor should know about?

    18. Do you smoke or chew Tobacco?

    19. Is there any past history of alcohol or chemical dependency or emotional disorder that may affect the care we provide you?

    20. Do you wish to talk with the doctor privately about anything?

    Women

    21. Are you pregnant or trying to become pregnant

    22. Do you have problems associated with your menstrual period?

    23. Are you nursing?

    24. Are you taking birth control pills?

    Financial Policy

    We are pleased to welcome you to our office. New patients are always appreciated. In order to assist you in making payments for your treatment, we provide the following options. Please read them carefully, and feel free to discuss them with us.

    PAYMENT: We accept all major credit cards, care credit and cash.

    IF YOU DO NOT HAVE INSURANCE: Payment is due in full at the time treatment is provided.

    IF YOU ARE INSURED: We will submit your form to your insurance carrier for you. You are responsible, at the time of your appointment, for any deductible or copayment NOT covered by the insurance company. Once our office has received payment from the insurance company, you will be billed, with 30 day terms, for any amount still owed. If there is a payment credit, you may apply the credit towards future dental work, or a check will be issued to you upon your request

    INSURANCE PATIENTS- PLEASE READ CAREFULLY: The amount of coverage paid by your insurance company may be based on your insurance company’s own reduced fee schedule for treatment and may be less than actual charges resulting in lower coverage to you. We have no control over this situation. Lower payment is a direct result of the plan selected by your employer. Please be advised, WE CAN NOT WAIVE THE CO-PAYMENT. We are required by law to collect co-payment.

    EXTENDED CARE CASES: Special arrangements may be made for extended care cases. Please see our Office Administrator.

    FINANCIAL CONSENT: I certify that I have read, understood, and agree to this financial policy, and that it applies to myself and my dependents.

    Notice of Privacy Practices for Protected Health Information

    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!

    With your consent, the practice is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.

    Example of uses of your health information for treatment purposes:
    A nurse obtains treatment information about you and records it in a health record. During the course of your treatment, the doctor determines a need to consult with another specialist in the area. The doctor will share the information with such specialist and obtain input.

    Example of use of your health information for payment purposes:
    We submit a request for payment to your health insurance company. The health insurance company requests information from us regarding medical care given. We will provide information to them about you and the care given

    Example of Use of Your Information for Health Care Operations:
    We obtain services from our insurers or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services.

    Your Health Information Rights:
    The health record we maintain and billing records are the physical property of the practice. The information in it, however, belongs to you. You have a right to:

    • Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office. We are not required to grant the request but we will comply with any request granted;

    • Request that you be allowed to inspect and copy your health record and billing record—you may exercise this right by delivering the request in writing to our office;

    • Appeal a denial of access to your protected health information except in certain circumstances;

    • Request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office;

    • File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information;

    • Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office. An accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing care;

    • Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office;

    • Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office.

    If you want to exercise any of the above rights, please contact Karen Hernandez at 718-899-7811, in person or in writing, during normal hours. She will provide you with assistance on the steps to take to exercise your rights.

    Our Responsibilities
    The practice is required to:

    • Maintain the privacy of your health information as required by law;

    • Provide you with a notice of our duties and privacy practices as to the information we collect and maintain about you;

    • Abide by the terms of this Notice;

    • Notify you if we cannot accommodate a requested restriction or request;

    • Accommodate your reasonable requests regarding methods to communicate health information with you.

    We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our "Notice" or by visiting our office and picking up a copy.

    To Request Information or File a Complaint
    If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact us at 718-899-7811.

    Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to NYC Oral Surgery. You may also file a complaint by mailing it or emailing it to the Secretary of Health and Human Services whose street address and phone number is 26 Federal Plaza New York, NY 10278.

    • We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the practice.

    • We cannot, and will not, retaliate against you for filing a complaint with the Secretary.

    Other Disclosures and Uses

    Notification
    Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.

    Communication with Family
    Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person's involvement in your care or in payment for such care if you do not object or in an emergency.

    Food and Drug Administration (FDA)
    We may disclose to the FDA your protected health information relating to adverse events with respect to products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.

    Workers Compensation
    If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

    Public Health
    As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

    Abuse & Neglect
    We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.

    Correctional Institutions
    If you are an inmate of a correctional institution, we may disclose to the institution, or its agents, your protected health information necessary for your health and the health and safety of other individuals.

    Law Enforcement
    We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement.

    Health Oversight
    Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.

    Judicial/Administrative Proceedings
    We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order.

    Other Uses
    Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided.

    Website
    If we maintain a website that provides information about our entity, this Notice will be on the website.

    Effective Date: April 17, 2009

    I hereby acknowledge that I have received a copy of this practice’s Notice of Privacy Practices. I have been given the opportunity to ask any questions I may have regarding this Notice.

    Covid19 Informed Consent

    I understand I am giving this informed consent to NYC Oral Surgery Associates, P.C. (the “Practice”) evidencing my educated decision to receive services at the Practice prior to any vaccine or known effective treatment to the CoronaVirus-COVID-19. I have been advised that the Practice has adopted recommended protocols for the prevention of COVID-19 at its facility. I have been advised I can request additional information prior to signing this consent, and at any time thereafter, as to the specific protocols in place regarding the Practice response to COVID19.

    By signing below, I acknowledge my understanding that the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and may still be highly contagious. I understand the Practice will be treating patients other than myself at its facility, as well as employing personnel who may be asymptomatic or qualified as “recovered” in accordance with CDC guidelines. I understand that it is impossible to determine who has it and who does not, at any given time, even as testing becomes readily available. I understand it is my responsibility to notify the Practice if I am medically “high risk” for any reason.

    By signing below, I hereby agree to release the Practice, and its owners, members, officers, employees, contractors, agents, and representatives (“Practice Representatives”), and covenant not to commence or maintain any action or proceeding against Practice and Practice Representatives, for or from any and all claims, causes of action, liabilities, damages, fees (including attorney’s fees and costs of defense) and demands whatsoever, in law or equity (“Claims”), which I (and my heirs, executors, administrators and assigns) shall or may have, or from any person or entity other than myself, for, upon, or by reason of my contracting COVID-19, including any claim resulting from my transmission of COVID-19 to any other person or thing. I hereby agree to indemnify and hold the Practice and Practice Representatives harmless from and against any and all Claims from or against any person or entity other than myself relating to my having or transmitting COVID-19.

    By signing below, I acknowledge I have read this Informed Consent and I hereby agree to its terms and I assume the risk of potential Covid-19 exposure by receiving treatment at the Practice.

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    Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.