Practice Without Pressure, Inc. Intake Form

Practice Without Pressure, Inc. Intake Form
Page 1
TODAY’S DATE:
Personal I
1) Individual’s Name:
2) Birth date:
Street:
3) PHONE #:
City:
State:
Zip:
Service provider:
Phone #:
Email address:
DDDS case manager:
Phone #:
Email address:
4) Contact information:
name, phone number, and
email
House manager:
Phone #:
Email address:
Nurse:
Phone#:
Email address:
Family contact:
Phone#:
Email address:
5) Race/Ethnicity
LEGAL GUARDIAN:
Phone#:
Email address:
 White
 Black
 Asian
 Native American
 Hispanic
 Prefer not to answer
6) Primary Diagnosis
7) Procedure(s) to practice




8) How does the individual
communicate?
9) What does the individual do
when they are afraid?
hair cut
dental appointment: cleaning
dental appointment: xray
other
 single words
 gestures
 voice output device
 hitting or biting
 laughing
 Cry
 Laugh
 Hit or bite self
 Withdraw
 blood draw
 nail care
 women’s health
 sentences
 sign language
 picture exchange
 eye movements
 other:
 non-word vocalizations
 facial expressions
 body movements
 crying
 Attempt to escape
 Fall asleep
 Hit or bite others
 Other: (describe)
 Hyperventilate
 Yell
 Self-stimulate
11) What is your goal for the
individual regarding the
procedure that we will be
working on?
PAGE 1 OF 9
Last name:
First name:
D.O.B.:
______________________
______________________
______________________
Practice Without Pressure, Inc. - Intake form, Where Are We, Consent - NEW PERSON FORMS A518 - PWP Intake Forms 1 040113
Practice Without Pressure, Inc. Intake Form
Appointment Information
1) Name of previous dentist or
doctor?
2) Date of last appointment? Is
there another appointment
scheduled?
4) Who will be bringing the
individual to the appointments
at PWP?
5) Has there been sedation or
restraint used to complete
appointments in the past?
6) What “reward” is the
individual willing to work for?








verbal praise:
special activity:
food:
toy:
game:
non-toy object:
money:
other
Office use only
File number
PAGE 2 OF 9
Last name:
First name:
D.O.B.:
_________________________
_________________________
Page 2 of 4
_________________________
Practice Without Pressure, Inc. - Intake form, Where Are We, Consent - NEW PERSON FORMS A518 - PWP Intake Forms 1 013013
Practice Without Pressure, Inc. Intake Form
Page 3
Where are we?
0
Procedure avoided or procedure completed with use of full physical
restraint.
1
Procedure abandoned partway through or procedure completed with
partial physical restraint.
2
Procedure completed with support person providing minimal
physical assistance and/or touching and/or significant verbal
encouragement
3
Procedure completed with support person within personal space
area but not touching but can be providing minimal verbal
encouragement.
4
Procedure completed with no physical restraint and no support
person in personal space area.
PAGE 3 OF 9
Last name:
First name:
D.O.B.:
__________________________
__________________________
__________________________
Page 3 of 4
Practice Without Pressure, Inc. - Intake form, Where Are We, Consent - NEW PERSON FORMS A518 - PWP Intake Forms 1 013013
Practice Without Pressure Consent for Treatment
Consent for Practice Without Pressure treatment for _______________________________________,
hereafter known in this document as PWP Participant.
(Last name, first name)
This consent shall remain in effect unless written notice received.
Supporting Consent
I, the parent, guardian, or supporting consent (circle one) of PWP Participant grant permission and accept responsibility for
the actions of PWP Participant. I agree to the terms of the hold harmless agreement below. I also agree to allow the staff of
PWP, and/or qualified medical/dental personnel to care for, treat, or authorize treatment and/or transportation for PWP
Participant and act as my agent in the care and treatment thereof, up to and including the attachment of debt liability in said
care and treatment. If there are any medical limitations or special needs regarding PWP Participant, please indicate below. .
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
I hereby state and declare that there are no special needs, additional problems or concerns other than those listed above,
regarding PWP Participant, which may be the cause of special concern to the staff of PWP and therefore agree to all terms set
forth herein. No application shall be considered without signature below.
Hold Harmless
The undersigned hereby agrees to hold harmless Practice Without Pressure, Inc. (PWP) or any staff or person involved with
PWP for any or all damages to persons and properties resulting from acts of God, loss, theft, vandalism or any physical or
psychological injury or medical emergency.
Further: the above mentioned persons, groups, or organizations shall be held harmless from any cause of action, claim or
petition, filed in any court or administrative tribunal, arising out of said event, including all costs, attorneys fees, judgments or
awards.
Use of Media Consent
The undersigned hereby agrees to the recording of images and/or audio by Practice Without Pressure, Inc. during practice
sessions or actual procedures. The images and/or audio recordings may be used by Practice Without Pressure, Inc. responsibly,
for training and/or promotional use, but may not be sold for any reason. I understand that the images and/or audio may be used
in a variety of media, including placement on websites and on internet outlets. The undersigned also authorizes PWP to use
content from interviews and other written communications that reflect the experience of the undersigned and designated
supporting parties for use in a variety of media to support the effectiveness of PWP.
________________________________________________
(Printed name of supporting consent individual)
__________ / __________ / __________
(Date)
_____________________________________________________
(Signature of PWP participant or supporting consent – circle one)
__________ / __________ / __________
(Date)
PAGE 4 OF 9
Last name:
First name:
D.O.B.:
_______________________
_______________________
_______________________
Practice Without Pressure, Inc. - Intake form, Where Are We, Consent - NEW PERSON FORMS A518 - PWP Intake Forms 1 013013
ASSIGNMENT OF BENEFITS FORM FOR ___________________________
(Last name, First Name)
FINANCIAL RESPONSIBILITY
All professional services rendered are charged to the patient and are due at the time of service, unless other
arrangements have been made in advance with our office. Necessary forms will be completed to file for insurance
carrier payments. If an appointment is cancelled without 24 hrs advance notice we may charge a missed appointment
fee.
ASSIGNMENT OF BENEFITS
I hereby assign all medical, surgical and dental benefits to which I am entitled. I hereby authorize and direct my
insurance carrier(s), including Medicare, private insurance and any other medical/dental plan, to issue payment
check(s) directly to Practice Without Pressure, Inc. for medical or dental services rendered to myself and/or my
dependents. I understand that I am responsible for any amount not covered by insurance.
AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize Practice Without Pressure, Inc. to: (1) release any information necessary to insurance carriers
regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment;
and (3) allow a photocopy of my signature to be used to process insurance claims for the period of lifetime. This order
will remain in effect until revoked by me in writing.
I have requested medical, surgical and/or dental services from Practice Without Pressure, Inc. on behalf of myself
and/or my dependents, and understand that by making this request, I become fully financially responsible for any and
all charges incurred in the course of the treatment authorized.
I further understand that fees are due and payable on the date that services are rendered and agree to pay all such
charges incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is
to be considered as valid as the original.
ACKNOWLEDGEMENT OF REVIEW OF NOTICE OF PRIVACY PRACTICES
I have reviewed this office’s Notice of Privacy Practices, which explains how my medical information will be used and
disclosed. I understand that I am entitled to receive a copy of this document.
________________________________________
Signature of Patient or Personal Representative
_______________________________________
Name of Patient or Personal Representative
__________________________________
Date
________________________________________
Description of Personal Representative’s Authority
FOR OFFICE USE ONLY:
Practice Without Pressure, Inc. made the following good-faith effort to obtain the above-referenced individual’s written
acknowledgement of receipt of the Notice of Privacy Practices:
(Identify the efforts made to obtain the individual’s written acknowledgement including the reason (if known) why the
written acknowledgement was not obtained.)
_______________________________________________________________________________________________
PAGE 5 OF 9
Last name:
First name:
D.O.B.:
Practice Without Pressure, Inc. - AssignBenefitsForm PWP - NEW PERSON FORMS A518 - PWP Intake Forms 1 013013
________________________
________________________
________________________
NAME: _______________________________
THE NEXT 2 PAGES ARE THE HIPAA NOTICE
AND DO NOT NEED TO BE RETURNED.
D.O.B.: _____________________
Last name:
First name:
Practice Without Pressure, Inc. - Medical History Form - NEW PERSON FORMS A518 - PWP Intake Forms 1 013013
D.O.B.:
PAGE 6 OF 9
___________________________________
___________________________________
___________________________________
HIPAA Notice of Privacy Practices
Practice Without Pressure, Inc.
2470 Sunset Lake Rd.
Newark, DE 19702
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 heath
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.
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
your health care pills, 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 but are not limited to: as required bylaw, Public Health issues as required by law,
Communicable Diseases as required by law, 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.
Practice Without Pressure, Inc. - HIPAA_Notice_PrivacyPWP - NEW PERSON FORMS A518 - PWP Intake Forms 1 013013
Your Rights
Following is a statement of your rights with respect to your protected health information.
a.
b.
c.
d.
e.
f.
You have the right to inspect and copy your protected health information. Under federal low, however,
you may not inspect or copy the following records; psychotherapy notes; information complied 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 your 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 what the restrictions to apply.
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 the 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 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 in 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 (302)832-2800.
Practice Without Pressure, Inc. - HIPAA_Notice_PrivacyPWP - NEW PERSON FORMS A518 - PWP Intake Forms 1 013013
Practice Without Pressure, Inc.
INSURANCE INFORMATION FORM
Today’s Date:
Dental
Women’s Health
Hair Cut
Blood Draws
OTHER
PATIENT INFORMATION
Patient’s last name:
Is this your legal name?
Yes
Middle:
First:
If not, what is your legal name?
Mr.
Mrs.
Miss
Ms.
Marital status:
Single
(Former name):
Mar
Div
Birth date:
Sep
Age:
Wid
Sex:
No
M
Street address:
Social Security no.:
Home phone no.:
(
P.O. box:
City:
Occupation:
Employer:
)
State:
ZIP Code:
Employer phone no.:
(
How did you hear about us? (Please choose one)
Dentist
Friend
F
Doctor
Family
)
Insurance plan
Yellow Pages
Hospital
Other
Comments:
INSURANCE INFORMATION
(PLEASE GIVE YOUR INSURANCE CARD/CARDS TO THE RECEPTIONIST)
Person responsible for bill:
Birth date:
Address (if different):
Home phone no.:
(
Occupation:
Employer:
Employer address:
Employer phone no.:
(
Is this patient covered by insurance?
Please indicate primary insurance
Met Life Dental
Yes
Subscriber’s name:
)
No
Medicare
Tri Care
)
Medicaid
BCBS
Aetna Dental
Delta Dental
Other
Subscriber’s S.S. no.:
Cigna Dental
Other
Birth date:
Group no.:
Policy no.:
Co-payment:
$
Patient’s relationship to subscriber:
Self
Name of secondary insurance (if applicable):
Patient’s relationship to subscriber:
Spouse
Child
Other
Subscriber’s name:
Self
Spouse
Group no.:
Child
Policy no.:
Other
IN CASE OF EMERGENCY
Name:
Relationship to patient:
Home phone no.:
Work phone no.:
(
(
)
)
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I
am financially responsible for any balance. I also authorize [Name of Practice] or insurance company to release any information required to process
my claims.
Patient/Guardian signature
Date
Page 9 of 9
Practice Without Pressure, Inc. - Insurance Information Form - NEW PERSON FORMS A518 - PWP Intake Forms 1 013013