1. No category

Patient Information
file'.lllllKucaba-server0.IiermanDataiDentalWriterNet/Reports/out.hfinl
Patient Registration
Patient
First
rn:l_-l
Chart
FORM DATE:
JJ-
ro,[--___l
Nam.
Mr
Middle
Initiatf-ll,ast
Name
Other Physician Name
Responsible Party (If someone other than patient)
Name
Patien t Information
Sfeet Address
sor"[*----l
Home Phone
Sex
Cell Phone (
Work Phone
Male
Birth Date:
zip
Female
Married
Divorced
Single
/t
Social Security Number
E-mail
Separated
)
Widowed
|]f=
Spouse Name
Student Status
Employed
Full Time
Part Time
Heigtrt:
[-l r..t l-l
rn.r,",
Fa*tly Dentist
Medical Insurance Information
Primary Medical Insurance Information
First Name of Insured:
Middle Initial
Self Spouse Child
Relationship to insured
Policy/Group No.
t/
Insurance ID No.
Employer
Insured Address
Last Name
Other
Insurance PIan Name
Ins. Company
if different than patient's
Steet Address
Street Address
City, State, Zip
City, State, Zip
Patient Signature:
Secondara Medical Insurance Information
First Name of Insured:
Policy/Group No.
Insured Birth Date
Employer
Last Name
Middle Initial
[-l
Insurance Plan or Program Name
Sex Male
Female
Insurance
ID No.
Ins. Company
Insured Address if different than patient's
Street Address
City, State, Zip
Sheet Address
City, State, Zip
Patient Signatwe:
I of
1
10/24/2011 10:59 AM
Medical Hi story Questionnaire
frle'.lllllKrrcaba-serverA{iermariD atalDentalWriterNet/Reports/out.hfinl
Medical History Questionnaire
/l
FORM DATE:
NAME:
DATE OF BIRTH:
Allergens
No known allergens
Iodine
Antibiotics
Latex
Aspitin
Local anesthetics
Barbiturates
Metals
Codeine
Penicillin
Medicine
Other
Medical
Significant
Current
Medical Condition
Nrurr- purt
Date
/ Note
-
Current
Medical Condition
Acid reflux
Cancer
Anemia
Chemotherapy
Arteriosclerosis
Chronic fatigue
Arthritis
Ckonic pain
futhma
COPD
Autoimmune disorder
Current pregnancy
Bleeding easily
Depression
Blood prossure - Hrgh
Diabetes
Blood pressure - Low
Drffrculty sleeping
Bruising easily
Dizziness
N.".r-
pur,
Date / Note
rr
Patient Signature:
1
of3
rc/2412011 10:55 AM
Medical Hi story
Questi onnaire
file'.1
I
ll lKucaba-serverA{iermanD atalDerfialWriterNet/Reports/orlt.hfinl
Medical History
Current
Significant
Medical Condition
Never past
Significant
rc/Note
/ Note
Date
Emphysema
n.:.I'T^. Date /Note
Medical condition
Muscular dystrophy
r-----l
Epilepsy
Nasal allergies
Fibromyalgia
Neuralgia
Glaucoma
0steoarthritis
Gout
Osteoporosis
Heart attack
Parkinson's disease
Heart disorder
P
Heart murmur
r----l
Heart pacemaker
r--]
rior orthodontic treatrnent
Psychiatric care
Radiation treatment
Heart valve replacement
Rheumatic fever
Hemophita
Rheumatoid arthritis
Hepatitis
Sinus problems
Hypertension
Sleep apnea
Hypoglycemia
Sroke
Immune system disorder
Tendency for ear infections
Kidney problems
Thyroid disorder
Liver disease
Tuberculosis
Meniere's disease
Tumors
Mifal valve
prolapse
t-*-]
Urinary disorders
Multiple sclerosis
Other
Medical Condition
Current Past
Date / Note
Medical Condition
Current Past
Date I Note
Confidential Medical History
Significant
Medical Condition
Recreational drugs
Current
Never Past
Date / Note
Significant
Medical
Current
Condition
Never
Past
Date / Note
HIV/AIDS
Surgical Operations
Appendectomy
Back
Ear
Patient Signature:
2 of3
1012412011 10:55
AM
Medi cal Hi story Questi onnaire
file.l/lllKucaba-serverA{iermanDatalDentalWriterNet/Reports/out.hfinl
Surgical Operations
Gallbladder
Lung
Tonsillectomy
Heart
Nasal
Uvulectomy
Hernia repair
Thyroid
Periodontal
Other
Family History
Has any member of your famrly (parent, sibling or grandparent) had:
Cancer
Heart disease
Diabetes
Ht& blogd pressure
Sroke
Sleep disorder
Obesity
Thyroid disorder
Father snores
Mother snores
Father has sleep apnea
Mother has sleep apnea
Social History
Patient's Occupation
Employer
Tobacco Use: Cigarettes
Never smoked
Current smoker
# of packs per
#
Other
Alcohol Use:Do you drink alcohol? yes
Caffeine
Intake: None
Coffee/Tea/Soda
tobacco:
No
aay[-_l
ofyears [_l
pipe Snuff Cigar
If yes, # of drinks pe.
# of cups per
Quit
When did you quit?
Chew
week:[--l
Oay:l-_l
Additional:
Regular
I authorize
e><ercise
Patient Signature
of
full report of examination findings, diagnosis, treatrnent program etc., to any referring or treating dentist or
physician. I additionally authorize the release of any medical information to insuranie companies or for legal doJumentatioi to process
claims. I understand that I am
less of insurance coverage.
the release
Patient Signature:
a
Ourr,F
ou,.,F
3 of3
l0/24l2AIl 10:55 AM
Review of Systems
file'.lllllKtxaba-server/NiermanD atalDerfialWriterNet/Reports/out.hfinl
Review of Systems
FORM DATE:
NAME:
DATE OF BIRTH:
JJtt
General
Within Normal Limits
Reported
Denied
Appetite changrs
Reported
Denied
Sensitivity to heat or cold
Reported
Denied
Marked weight change
Reported
Denied
Tires easily
Reported
Denied
Nrght sweating
Reported
Denied
Unusual weakness
Reported
Denied
Recent trauma or infection
Reported
Denied
Other
Reported
Denied
Head, Eyes, Earso Nose and Throat
Within Normal Limits
Reported
Denied
Dizziness
Reported
Denied
Sore gums or tongue
Reported
Denied
Headaches
Reported
Denied
Sore throat or hoarseness
Reported
Denied
Nose bleeding
Reported
Denied
Sw
Reported
Denied
Ringng in ears
Reported
Denied
Trauma
Reported
Denied
Sinus infections
Reported
Denied
Ulcers or lumps in mouth
Reported
Denied
allowing di{ficulties
Other
Reported
Denied
hleck
Reported
Within Normal Limits
Denied
Neck pain
Reported
Denied
Reported
Denied
Stiffiress
Other
Reported
Denied
Lungs
Within Normal Limits
Reported
Denied
Persistent cough
Reported
Denied
Swelling of ankles
Reported
Denied
Shortrress of breath
Reported
Denied
Wheezing
Reported
Denied
Other
Reported
Denied
Heart
Reported
Within Normal Limits
Denied
High blood pressure
Other
Reported
Denied
Reported
Denied
Patient Signature:
I of2
10124/20ll l0:53 AM
Abdomen
Reported
Within Normal Limits
Heart burn
Denied
Other
Reported
Denied
Reported
Denied
Hematologic
Within Normal Limits
Reported
Denied
Anemia
Reported
Denied
Bleeding disorders
Reported
Denied
Reported
Denied
Bruises easily
Other
Reported
Denied
Bone Joints
Within Normal Limits
Reported
Denied
Back pain
Reported
Denied
Muscle cramps
Reported
Denied
Joint stiffness
Reported
Denied
Myalga
Reported
Denied
Other
Reported
Denied
Neurologic
Within Normal Limits
Reported
Denied
Cephalgia
Reported
Denied
Headaches
Reported
Denied
Dizziness
Reported
Denied
Muscle weakness or paralysis
Reported
Denied
Other
Reported
Denied
Reproductive
Reported
Within Normal Limits
Impotence
Denied
Reported
Denied
Reported
Denied
Lack of sex drive
Other
Reported
Denied
Other
Within Normal Limits
Other
Reported
Denied
Reported
Denied
Patient Signature
I authorize the release of
full report of examination frndings, diagnosis, treabnent program etc., to any referring or treating dentist or
physician. I additionally authorize the release of any medical information to insurance companies or for legal documentation to process
claims. I understand that I am
for all
for freatment to me
less of insurance coverage.
Patient Signature:
a
Date:l
Ou,.,F
2 of2
10124/2011 10:53 AM
Sleep Consulation
file.l ll I lKr:r;aba-serverAlliermanData/DentalWriterNet/Reports/out.htnl
Sleep Consultation
Version: SLPQVI
CURRENT DATE:
NAME:
_-JJ-
DATE OF BIMH:
lt
FEMALE
contactton
Referring PhvsicianJ
2
WFI,AT ARE THE CHIEF
COMPIAINTS FOR
WHICH YOU ARE SEEKING TREATMENT?
Then rate your complaints for frequenry and intensrty
Frequency
l.SELDOM 2.OCCASIONAL
1.
MALE
number your complaints',uth g1 being the
most severe, :? the next most severe, etc.
3.FREQUENT
4-EVERYDAY
Please
lntensity
O=NO PAIN and 10 is MOST SEVERE PAIN
Number
#1
:
Frequency
l-4
the most severe symptom
CPAP inrolerance
n
L__J
Diffrculty falling asleep
Fatigue
L_J
Frequent heav.v snoring
n
L-l
Frequent heary snoring which affects the sleep
others
of
Other:Write In
IntensityNumber
1-10
TT
nn
n
TT T
TT I
TN T
Frequency
#1 = the most severe
symptom
Gasping when waking up
Nighttime choking spells
Significant daytime
drowsiness
Sleepiness
while driving
Witnessed apneic events
l-4
Intensif
1-10
T
I l
n n
t-t
lt
n
n T
SLEEP STUDIES
If you have had a Sleep Study, please check one of the following:
Home Sleep
Study
Polysomnogaphic evaluation at a sleep disorder center
Sleep Center Name:
Sleep Study Date:
FOR OFFICE USE ONLY
The evaluation confirmed a diagnosis
The evaluation showed:
during REMSupine Side
anRDr"fl-l
anAHr"fl-l
a nadir
spoz
n n
n n
ofl-l reol-l
oDrl-l(o,cypn
Slow Wave
Sleep Decreased
None
REM Sleep
Decreased
None
Desaturation rndex)
Patient Signature:
I of4
10124/2011 10:53 AM
Sleep Consulation
file
.
IIII
lKucaba-serverAli ermanD ata/DefialWriterNet/Reports/out. htrnl
Additional Questions
Yes
No
fue you a current CPAP (Continuous positive Air
If
Pressure) user?
settinp:
Yes, what are the current CpAp
CPAP Intolerance
If you
(continuous Positive Airway pressure device)
have attempted treatment with a CPAP device, but could not tolerate
Mask leaks
Inability to get the mask to fit
please
fill in this section:
CPAP restricted movements during sleep
properly
Discomfort from headpar
Disturbed or intemrpted sleep
An unconscious need to remove the
CPAP
CPAP does not seem to be effective
Pressure on the upper lip causing tooth
problems
Does not resolve symptoms
related \r
NotsY
Latex allerg'
Noise disturbing sleep and/or bed
parher's sleep
it
C
.
Cumbersome
laustrophobic association
s
Other
include:
Other Therapy Attempts
Dieting
Smoking cessation
Weight loss
CPAP
SurSry Qvuloplasty)
BiPap
Surgery (Urulectomy)
Uvulectomy (but continues to have qzmptoms)
Pillar procedure
Uvuloplasty (but continues to have symptoms)
Epworth Sleep Questionnaire
How likely axe you to doze off or fall asleip in the following siluations?
No
Slight
Moderate
High
chance of dozing chance of dozing chance of dozing chance oi dozing
Sitting and reading
Watching TV
Sitting inactive in public place (e.g. a theater or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
Patient Signature:
2of4
10/24/2011 10:53 AM
Sleep Consulation
file'.lllllKrrcaba-serverAliermanDatalDentalWriterNet/Reports/out.hrnl
Epworth Sleep Questionnaire
How likely ane you to doze off or fall asleep in the following situations?
No
chance
ofdozing
Slight
chance
Moderate
ofdozing
chance
ofdozing
High
oidozing
chance
In a car, while stopped for
a
few minutes in traffrc
Fatigue Scale
Durine the prst
I feft
vtek
<
1234567
> yes
No
fatigued and had less motivation
I fett fatigued and did trot desfe !o e,€rcis€
I felt fatigued often
I felt fatigue that interfered with my physical functioning
I feh fatigued which caused me frequent problems
I felt fatigued which prevented sustained physical functioning
I felt fatigued and couldn't carry out certain duties and responsibilities
Fatigue was amongmy three most disabling symptoms
Fatigue interfered with my work, famity or social life
Total
Score'f]
Berlin Questionnaire Sleep Evaluation
l. Complete the following:
7.
Height:m,nt
weight: []u. ee' []
How often do you feel tired or fatigued after you sleep?
nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
never or nearly never
8.
Drring your waketime, do you feel tired, fatigued or not up to par?
no
nearly every day
don't know
3-4 times a week
l-2 times a week
l-2 times a month
Ayou snore: (Answer questions 3-6)
never or nearly never
Patient Signature:
3
of4
10,24i2011 10:53 AM
Sleep Consultation
file./ll/lKucaba-serverA'liermanData/DentalWriterNet/Reports/out.hfinl
Berlin Questionnaire Sleep Evaluation
3. Your snoring is?
sli$tly louder than breathing
as loud as talking
louder than talking
very loud. Can be heard in adjacent rooms
9. Have you evernodded
ofror fallen
asleep while driving a vehicle?
es
4.
How often do you snore?
nearly every day
3-4 times a week
If yes, how often does it
l-2 times a week
occur?
nearly every day
l-2 times a month
3-4 times a week
never or nearly never
1-2 times a week
1-2 times a month
Has your snoring ever bothered other people?
never or nearly never
6. Has anyone noticed that you quit breathing during your sleep?
10. Do you have high blood pressure?
es
near$ every day
no
3-4 times a week
don't know
l-2 times a week
l-2 times a month
never or nearly never
scoring Questions: Any answer within a box is a positive response
Scoring Categories
category
I
is positive
with 2 or more positive responses to questions 2-6
Category 2 is positive with 2 or more positive responses to questions
7-9
(BMI
Category 3 is positive with a positive response to question l0 and/or a BMI >
lhd k*1, 2 * T* pottbb
t u hi$ lik.lihooa of lbep
:
30
Bo4t Mass Index)
I
--__l
dsordered breathing.
Patient Signature
I authorize the release of
a
claims. I understand that
I am
full report of examination findings, diagnosis]treaftnent program etc., to any referring or treating
dentist or
for treatment to me re
I certify that the medical
Patient SiErature:
4of4
10/2412A11
l0:53 AM
Sleep Consultation
file .l / I I lKucaba-serverA{iermanData/DentalWriterNet/Reports/orrt.hfinl
Sleep Consultation
Version: SLPQV2
NAME:
CURRENT
DATE OF
BIKIH I
I
DATE:
MALE
Contact ID
2
WHAT ARE THE CHIEF COMPI.AINTS FOR
WHICH YOU ARE SEEKING TREATMENT?
Please
I
FEMALE
Referrins PhvsicianJ
1.
I
Then rate your conrplarnts for frequenry and intensrty
Frequerrcl
1-SELDOM 2.OCCASIONAL 3.FREOUENT
4-EVERYDAY
number vour complaints with =1 being the
=2 the next most severe, etC.
mOSt Severef
lntensity
0=NO PAIN and 10 is MOST SEVERE PAIN
Number
#l
:
Fre quency Intensity
l-4
the most severe symptom
CPAP intolerance
I
Diffrculty falling asleep
n
Fatigue
I
[-l
I I
Frequent heary snoring
Frequent heavy snoring which alfects the sleep
others
Other: Write In
of
Number
Frequency Intensity
l-10 #l = the most severe symptom
TN
IT T
rT
n
NT l
TN l
Gasping when waking up
Nighttime choking spells
Significant daytime
drowsiness
Sleepiness while driving
Witnessed apneic events
t-4
TT
rT
TT
IT
NT
l-10
Patient Srgnature:
I of4
l0l24l20ll l0:56 AM
Sleep Consultation
file'./llllKtacaba-serverA.iiermariDatalDentalWriterNeVReports/out.hfrnl
Epworth Sleep Questionnaire
How likely ane you to doze off or fall asleep in the following situations?
No
Slight
Moderate
High
chance of dozing chance of dozing chance of dozing chance of dozing
Sitting and reading
Warching
TV
Sitting inactive in public place (e.g. a theater or a meeting)
fu
a passenger
in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly affer a lunch without alcohol
In
a car, while stopped
for a few minutes in traffrc
SLEEP STUDMS
If you
have had a Sleep Study, please check one of the following:
Study
Home Sleep
Polysomnogaphic evaluation at a sleep disorder center
Sleep Center Name:
sleen Studv ou*,
l-/-l-_-l
FOR OFFICE USE ONLY
The evaluation confirmed a diagnosis
The evaluation showed:
EN[]T
nnnr
during REMSupine Side
an RDI
an
a
of
AHI of
nadir spo2
o{-l re0l-loDl[l(oxygen
Sleep Decreased
REM Sleep
Decreased
Slow Wave
Desaruration Index)
None
None
Additional Questions
Yes
No
fue you a current CPAP (Continuous Positive Air
If
Pressure) user?
settings:
Yes, what are the current CPAP
Patient Srgnature:
2of4
10/2412011 10:56 AM
Sleep Consulation
file'. l l l l lKucaba-serverA{i ermanData/DentalWriterNeVReports/out. hrnl
CPAP Intolerance
If you
(Continuous Positive Airway Pressure device)
have attempted treatment with a CPAP device, but could not tolerate it please
Mask leaks
Inability to get the mask to fit
fill in this section:
CPAP restricted movements during sleep
properly
CPAP does not seem to be effective
Pressure on the upper lip causing tooth
Discomfort from headpar
problems
Disturbed or intemrpted sleep
Does not resolve syrnptoms
related rr
NotsY
Latex allerg,
Noise disturbing sleep and/or bed
partner's sleep
C
An unconscious need to remove the
CPAP
.
Cumbersome
laustrophobic associations
Other
Other Therapy Attempts
include:
Dieting
Smoking cessation
Weiglrt loss
CPAP
Swgery Qvuloplasty)
BiPap
Surgery (Uvulectomy)
Uvulectomy (but continues to have symptoms)
Pillar procedure
Uvuloplasty (but continues to have symptoms)
History Of Treatment
Practitioner's Name
Specialty
Tieatment
Approximate Date
Sleep History
Previous Diagnosis
Have you been previously diagnosed with Obstructive Sleep
If yes, how long ago was it?[-lr
tmber
years
ago
Apnea?
yes
No
Months ago Days ago
Sleep:
Patient Signature:
3of4
10/24/2011 l0:56 AM
Sleep Consultation
frI e . I I I I I Kucab
a-s
erv erA{i ermanDatalDental Wri terNet/Re
p
ortsl out.
htnl
Sleep History
Sleep Onset
Bruxism
Latency
[]
Sleep
minutes
Normally goes to bed
Dry mouth
*fl
E:rcessive movements
Hours of sleep per night[--heu15
Gasping
PM
yes
No
If yes, name the
medication:
Hypnagogic
Hallucinations
Restless legs
Waking up and having diffrculty returning
to sleep
Dreaming
Getting up <number
ltimep per
I
AM
Aid
night
of [--_lFrequency of nocturnal
I
lurinarion (# of rimes)
Wtnessed apneas are:
Worse
d*ing
Worse following alcohol late at
supine
mdlt
sleep
Wake
Sleepiness while driving
Yes
No
Risks Discussed
Yes
No
The patient:
Awakens unrefreshed
Snoring is reported as:
Frequency
seldom
Worse during supine sleep
never
Worse following alcohol late at night
darly
often
lisht
moderate
Severity
loud
Patient Signature
I authorize the release of a full report of examination findinp, diagnosis, Gaftnent program etc., to any referring or treating dentist or
ician. I additionally authorize the release of any medical information to insuranie companies or for legal
doJumentatioi to process
laims. I understand that I am
Patient Signature:
I certify that the medical
4 of4
rc/24/?A11 10:56 AM
Affidavit For Intolerance To CpAp
I have attempted to use the nasal CPAP to manage my sleep related breathing disorder
(apnea) and find it intolerable to use on a regular basis for ihe following reason(s):
D
Mask Leaks
f
An Inability to get the Mask to Fit properly
tr
Discomfort Caused by the Straps and Headgear
,,,;
tr
Disfurbed or Intemrpted Sleep Caused by the Presence of the Device
E
Noise From the Device Disturbing Sleep or Bed/Partner's Sleep
A
CPAP Restricted Movements Durkij Sleep
e
CPAP Does Not Seem To Be Effective
e
Pressure
e
Larex Allergy
e
Claustrophobic Associations
a
An unconscious Need to Remove the cpAp Apparafus at Night
U
Other
on The Upper Lip
Causes Tooth Related problems
Because of my intolerance/inability to use the CPAP, I wish to have an alternative
method
treatment. That form of therapy is oral appliance therapy (oAT).
Signed
Date
of
Release of Patient's Records
'l'hc toI
lorving inlbr"rlatiorr is for recorcls on:
I)atient's rrarne:
Ilirthdate.
r\clcilcss:
[-clc'lthorre:
hercbv authorize:
to
re Ie ase
records to: Dr'. Waltcr J Krrcaba. DDS
IVl
S. PA
lnlblnlrtion to be released:
t
I
f
fl
I
Dcrrtal rccorcls
Paticnt reltort(s) prcpareci 1l'onr this ot'f rcc
-fest
r"esults
- Itays
Polysonlnography(PSC's)
X
Ite e ords arc ncede cl lbr':
:l
t
I
:l
f
C'oorclinatins Carc ol'Or-al Appliance 'fherap;, fbr Obsrrurctive Slcep Apnca
Insurarrce
Cornrtrunication lvitli yoLlr other health care pro\,'iders
[-csul I)ur-1;oscs
C'ctntinuinil crirc
Orhcr
i Lrrttlerstancl tltat thc ittlortttatiort
to be released may irrclucle, history, cliagnoses,
ar-icl or.rr.e:rrprr,i1
olllce. I also uncierstand that t[is agtftorizitiop llav bc r-cr..;kctj l)
thc pc|sort giVills iirrthorizatiott by a tvritlcn and ciatcd noticc. except to thc extept thlt rir:eio.jrr-,,
ol'infor-tttatiotl has bcen ntacJe prior to reccilrt of the revocation. This authorizatiop g'ill crltre
'./,,
tlrtVs 1l'ont thc date ol signatllre. I liave read and urnderstancJ this consent and I irave
sisiretl r:
r oluntlrilt' and o1'rnv o\\ t.t tl.ce ri,ill.
o1'tilcrrll))'r'e latctl to tilis clcntal
SigrtrtLrr"e
Date
i'l.rlltlritiort ol'r'ctJisclosttre : l-lris inlbrrtration has bcen clisclose d to t,ou fl'ont rccorcls, u
h iclt are
conilcicrrtial. \'ou iire ltrohibited fl'onr rlakiltg any firrther clisclosur.e ol 'it lvithoLrt
thc slleciflc u riricri
collscllt of'the I)ersoll to ti'hont it pcrtains, or AS othenvise
1tc;rrritteci by, la*'. A gerreral arrtltorizution ii,r
t'e leasc ol-delltal or otlter inlbrnration is not sLrff
rcient lor tiris llurpose.
I'lcuse lar rlre
lollo* ing i'fbrrlation to (864) 5g5-0469.
FINANCIAL POLICY
As n conLlrtion olyour treatment by this office, financial arrangements must be made in advance.
Paltctlts rr lro carry dental insurance understand that all dental services fumished are charged direcrly ro
rhe p.rienr ;rrrd rhat he or she is personally responsible for payment ofall dental services.
This otllce rvill help prepare the patient's insurance forms. However, this periodontal office cannor
r!'ndcr service on t)re assumption that our charges will be paid by an insurance company. Medicare
Insurance rvill only be liled for Sleep Apnea treatment. MEDICAID INSURANCE WILL NoT
FILED BY OUR OFFICE. Repeated insurance filings will be subject to a small administrarive
char'rc ol S 10.00. A service charge of ltA o/o per monlh (18% annual) on the unpaid balance will be
cltrtur'd on all accounts exceeding 60 days, unless previously written financial arrangements are
sirristlcrl. we accept cash, checks, Visa, Mastercard, American Express and care credit.
BllolilaN
APPOINTMENTS:
t
.
Please call or.rr ot'fice at least 24 hours in advance to cancel or reschedule appointments. Patients thar
do not cail and fail to show up for scheduled appointments will be charged a $25.00 ,.No Show
Charge".
I],
II I, I.-.\S
I
OF I NFOR]VTATION
131'srgrrirrg rhis paper, you agree that we can release your information conceming the treatmenr
necessAlv r.vith yottr General Dentist or any other Doctor involved with your care. Please
back oI rlris page lor authorization to release your information to a family member.
I)rr tic n
t
Si gn
ittu l'e:
Il.e.s1ton.sible
Plrt.r Signature:
Date:
Relationship
to Patient:
fill
our rhe
Authorization for Release of Information
Name of Patient
Date of Birth
Walter |. Kucab4 D.D.S., M.S, P.rL
patient or others in keeping with the patient's instructions.
Entity to Receive Information.
i;H*ffi+iJ',jffig?iT#*t.
Check each person/entity that you approve to
receive information.
Deccdption of information to be relessed.
Check each that can be given to person/entiry on
the left in the same section.
fl
E Results of lab testVx-rays
Voice Mail
f, oth.t
fl spout.
[l
P..nt
(provide name)
D
-J]
Financial
Vr"aical as follows:
Q Finansial
E rtl"Oical as follows:
fl
Otr,er (provide name)
E Financial
E Uraical as follows
Patient Information
I understand that I have the right to revoke this authorization at any time and that I have the right to
inspect or copy the protected health information to be disclosed as described in this document. I
understand that a revocation is not effective in cases where the information has already been disclosed
but wrll be effective going forward.
I understand that information used or disclosed as a result of this authorization nay be subjest
to
redisclosure by the recipient and rnay no longer be protected by federal or
state law.
I understand
that I have the right to refuse lo sign this quthorization md that my treatment
will not be
cortdinoned on signing. This authorization shalf be in effea until revoked bv the nnrient
Date
Signarure of Patient or personal Representative
Description of Personal Representative's Authority (attach
necessary documentation)
Revised October 2007
Complaints
Complaints about your privacy rights, or how this practice has handled your
health information
should be directed to our privacy officer by calling this otfice.
lf you are not satisfied with the manner in which this office handles your complaint, you
may submit
a formal complaint to,
DHHS, Office of Civil Rights
200 lndependence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201
This notice is effective as of
I have read the Privacy Notice and understand my'- rignts contained in the notice.
By way of my signature, I provide this practice with my authorization and consent to use and
disclose my protected health care information for the purposes of treatment, payment and health
ca(e operations as described in the privacy Notice.
Pattent's Name (print)
Patient's Signature
Date
Authorized Facility Signature
Date
a
T5e Notice of Privacy Practices Brochure is located in the office.