Patient Form Packet
                                                                                                        
 
Pa#ent Registra#on 
 
General Informa#on 
First name – Pa-ent   Middle name    Last name - Pa-ent 
___________________________  _____________________ ________________________ 
Nickname/Preferred Name  Prefix/Honorific                Degree/Suffix 
____________________________      _________________                     ________________________ 
Gender      Pa-ent date of birth  
____________________________ ______________________ 
 Preferred language    Email address    Marital status 
____________________________ ______________________ __________________ 
 
 Contact Informa#on  
Home # _____________________________ 
Work # ______________________________ 
Mobile #_____________________________ 
 
Pa-ent mailing address:    Pa-ent billing address: 
_____________________________  ___________________________ 
_____________________________  ___________________________ 
_____________________________  ___________________________ 
 
Has the main contact for the family changed since your last visit? ________ 
Has the main person responsible for payments for the family changed since your last visit? _______     
 
 
 
Other Informa#on  
Occupa-on: ___________________________ 
Employer: _______________________________  Employer phone #:_______________________ 
Social Security number:___________________                 Driver's license number:__________________ 
Previous provider:_________________________  Previous provider phone:_________________ 
Non-verbal communica-on needed with pa-ent: ___________ 
Has your insurance informa-on changed since your last visit? _____________  
 
 
 
 
Signature: ________________________________________  Date: __________________  
                                                                             
 
Medical History 
 
General Informa4on 
First name – Pa-ent   Middle name    Last name - Pa-ent 
___________________________         _____________________  ________________________ 
Gender      Pa-ent date of birth   Email address   
____________________________                   ______________________  ______________________ 
 
Emergency Informa4on 
Emergency Contact 
______________________________________________ 
Emergency Number 
______________________________________________ 
Family Doctor 
______________________________________________ 
Family Doctor # 
______________________________________________ 
 
Dental Informa4on 
Have you had any problems associated with previous dental treatment? ____________________    
Is this your child's first dental visit? ______________________________________________________   
Do your gums bleed when you brush or floss? ____________________________________________ 
 Are you currently experiencing dental pain or discomfort? _________________________________ 
Does your child have any habits such as pacifier or thumb? ________________________________ 
 Do you have any clicking, popping or discomfort in your jaw? ______________________________ 
Does your child need an-bio-c treatment prior to their dental appointment? (not for dental infec-on) 
____________________________________________________________________________________________ 
Do you grind your teeth? _______________________________________________________________________  
Have you ever had a serious injury to your head, neck or mouth? ________________________________ 
 
Medical Informa4on 
Allergies 
____Acetaminophen/Tylenol®          ____Animals      ____Ar-ficial dyes          ____ Aspirin  
____Bactrim        ____Codeine      ____Erythromycin          ____Food  
____Ibuprofen/Motrin®/Advil®          ____ Iodine   ____ Latex      ____Hay fever/seasonal                  
____Local anesthe-c         _____Metals  _____Milk                           ____Morphine  
____Penicillin       _____Sulfa  _____Tetracycline            ____Other 
 
Condi4ons 
____Abnormal/excessive bleeding                 _____ADHD                 ____AIDS or HIV infec-on                
 _____Anemia    ____Anxiety        ____Asthma          
_____Autoimmune Disease               ____Au-sm            ____ Cancer/chemotherapy/ radia-on treatment   
 _____Bronchi-s                                    ____Cardiovascular disease               _____Cerebral Palsy CleY Lip/Palate     
_____ Damaged heart valves                         ____Developmental Delay                 _____Diabetes       
_____Down Syndrome                                           ____Epilepsy Fain-ng spells or seizures       ____G.E. Reflux/persistent heartburn  
 _____Hearing difficul-es    _____Heart murmur     _____Heart rhythm disorder  
______Hemophilia     _____Hepa--s, jaundice or liver disease     _____Kidney problems   
______Liver Disease     _____Other congenital heart defects  _____Psychological Disorders   
______Rheuma-c fever    _____Sickle Cell Anemia    _____Speech Delay 
______ Spina Bifida     _____Systemic lupus                      _____Erythematosus  
______Thyroid problems    _____TMJ Disorder     _____Tumors or growths  Other 
 
Details: 
___________________________________________________________________________________________ 
Please indicate if you have or any of the following diseases or problems: 
___________________________________________________________________________________________ 
 
Preferred pharmacy: 
_____________________________________________________________________________________________ 
Pharmacy #: 
_____________________________________________________________________________________________ 
 Date of last physical exam: 
_____________________________________________________________________________________________ 
Have you had a serious illness, opera-on or been hospitalized in the past 5 years? 
 
Are you taking any prescrip-on or over-the-counter medicines?  
_____________________________________________________________________________________________ 
Do you have sleep apnea? 
_________________________________________________________________________ 
Please list any surgical procedures you have undergone and when they occurred. 
_____________________________________________________________________________________________ 
Has a physician or previous den-st recommended that you take an-bio-cs prior to your dental treatment? 
_____________________________________________________________________________________________ 
Physician’s phone number: 
__________________________________________________________________ 
 
 
Please read the above and understand that the informa-on provided in this form is accurate. A truthful health history will help 
ensure the best possible dental treatment. The informa-on provided here will be used by the doctor and pa-ent to inform any 
further discussion of the pa-ent's health prior to or during an appointment. By signing below, you also acknowledge that you 
will not hold the den-st, the dental prac-ce or any other member of the prac-ce staff responsible for any ac-on or lack of 
ac-on because of errors or omissions that may have been made during the comple-on of this form. 
 
 
Signature: _________________________________________   Date: ________________ 
Financial Responsibility 
INSURANCE  
Our office is commi,ed to helping our pa5ents maximize their benefits. Your es5mated pa5ent por5on, deduc5bles, co-pay 
amounts, and non-covered services must be paid at the 5me of service. As a service to our pa5ents, we will bill insurance 
companies for services and allow them 30 days to render payment in full. AEer 30 days you are responsible for the en5re 
balance, and it will be due in full. Insurance policies   
vary greatly therefore we can es5mate your coverage in good faith but cannot guarantee coverage due to the complexi5es of 
insurance contracts. Any ques5ons regarding your benefits should be directed to your insurance carrier directly. 
MISSED APPOINTMENTS  
Once an appointment has been made, please remember that this 5me has been reserved specifically for you. If you are unable 
to make it to your child’s appointment, we ask that you give our office 24 business hours before rescheduling the appointment. 
A standard fee of $40.00 dollars will be charged to your account for any dental appointment cancelled or failed within 24 
business hours of the scheduled appointment 5me, $60 dollars for the second appointment, $80 dollars for the third 5me and 
possible dismissal from our office the fourth 5me. If you have more than one child, each child is one appointment. Note: All 
cancella5on fees must be paid prior to scheduling future appointments with our office. When we reserve 5me for you, we 
require all that 5me to provide you with the best quality work possible. When you are late it decreases our ability to accomplish 
this. If you arrive 15 or more minutes late the appointment is considered missed and the missed appointment fee will apply, we 
will then reserve the right to reschedule your appointment.  
PAYMENT TYPES  
We accept VISA, MC, AMEX, DISCOVER, ZELLE. We also offer care credit and spring stone as a third-party payment plan in our 
office. WE DO NOT ACCEPT CHECKS. 
FINANCIAL CHARGES AND COLLECTION FEES  
Monthly financial charges of 5% may be applied to all balances not paid within 30 days of the monthly billing date. If this 
account goes unpaid, and we are forced to use an outside collec5on agency and / or an a,orney, it is understood and agreed 
that up to 40 % of the principal amount due will be added as collec5on fees. If we are forced to file a lawsuit, it is understood 
and agreed that you will be liable for all court costs whether judgment has been entered or not.  
FINANCIAL CONSENT  
The Responsible party agrees to be fully responsible for total payment of treatment performed in this office. 
 __________________________________________________   
ACKNOWLEDGEMENT OF RECEIPT:   I acknowledge that I received a copy of the financial consent. 
ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES  
 
The Loose Tooth Pediatric DenAstry and Aligned OrthodonAcs 
15041 S. Van Dyke Rd, #105  
Plainfield, IL   60544  
815.267.7299  
 
Acknowledgement  
I hereby acknowledge that I have received and reviewed a copy of The Loose Tooth and Aligned 
OrthodonNcs’ HIPAA NoNce of Privacy PracNces.  
 
I understand that The Loose Tooth and Aligned OrthodonNcs’’ HIPAA NoNce of Privacy PracNces may 
change periodically and that I am enNtled to receive a copy of The Loose Tooth and Aligned 
OrthodonNcs’ revised HIPAA NoNce of Privacy PracNces upon request.  
 
I understand that, if I have quesNons about HIPAA NoNce of Privacy PracNces, I may contact Rhiannon 
Holcombe, DDS.  
 
I understand that it is my right to refuse to sign this Acknowledgement should I so choose, and that The 
Loose Tooth and Aligned OrthodonNcs will not refuse treatment to me if I refuse to sign this 
Acknowledgement.  
 
I further understand that I may contact the Secretary of the U.S. Department of Health and Human 
Services should I have concerns regarding The Loose Tooth and Aligned OrthodonNcs’ privacy policies 
and procedures. For informaNon on how to contact the U.S. Department of Health and Human Services, 
please ask Rhiannon Holcombe, DDS, noted above, for assistance.  
 
  
 
 Signature:_________________________________________________                   Date:______________ 
  
 
FOR OFFICE USE ONLY  
 
  
 
The Loose Tooth and Aligned OrthodonNcs made a good-faith effort to obtain Acknowledgement, from 
the paNent noted above, of receipt of its HIPAA NoNce of Privacy PracNces. In spite of these efforts, Th 
Loose Tooth and Aligned OrthodonNcs was unable to obtain a signed Acknowledgement for the following 
reason(s):   
 
o Refusal to sign Acknowledgement on _____________________________, 20______.  
 
o CommunicaNons barriers prohibited us from obtaining a signed Acknowledgement.  
 
o An emergency situaNon prohibited us from obtaining a signed Acknowledgement.  
 
o Other (Describe):_______________________________________________________  
 
  
 
  
 
AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION 
The Loose Tooth Pediatric Den>stry and Aligned Orthodon>cs 
15041 S Van Dyke Rd Suite 105 
Plainfield, IL 60544 
 
Pa$ent Authoriza$on  
I hereby authorize The Loose Tooth Pediatric Den$stry and Aligned Orthodon$cs to release, use and/or 
disclose my protected health informa$on as directed below.  
 
Health Informa$on  
This Authoriza$on pertains to the following types of protected health informa$on about me:  
o All dental records received or created by The Loose Tooth Pediatric Den$stry and Aligned Orthodon$cs 
o Dental report(s) (please specify)  
o Dental image(s) (please specify)  
o All dental records rela$ng to (specify injury or condi$on)  
o Other (please describe)  
 
 I understand that, per my voluntary request, this Authoriza$on permits The Loose Tooth Pediatric 
Den$stry and Aligned Orthodon$cs to release, use or disclose my protected health informa$on and 
transfer dental x-rays only to authorized par$es. I further understand that I may revoke this 
Authoriza$on at any $me by providing wriLen no$fica$on to The Loose Tooth Pediatric Den$stry and 
Aligned Orthodon$cs. Revoca$on of this Authoriza$on will be effec$ve on the date no$ce is received 
and processed by The Loose Tooth Pediatric Den$stry and Aligned Orthodon$cs except to the extent that 
ac$on has already been taken in reliance upon this Authoriza$on.  
 
 Authoriza$on Expira$on  
This Authoriza$on will expire one (1) year from the date that I sign it, unless I indicate an alterna$ve 
expira$on date below:  
  
 
  
 
AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION 
Know Your Rights  
Your decision to sign this Authoriza$on is voluntary. THE LOOSE TOOTH PEDIATRIC DENTISTRY AND 
ALIGNED ORTHODONTICS will not refuse treatment to you if you refuse to sign this Authoriza$on.  
When your protected health informa$on is released as provided by this Authoriza$on, please be aware 
that the named recipient (above) may not be legally obligated (under HIPAA) to obtain an authoriza$on 
for subsequent re-disclosure of your protected health informa$on.  
 
 
Signature: _________________________________________ Date: ________________ 
 
I have read the contents of this Authoriza$on, and I confirm that the contents are consistent with my 
direc$ons. I understand that by signing this Authoriza$on, I am permiZng THE LOOSE TOOTH PEDIATRIC 
DENTISTRY AND ALIGNED ORTHODONTICS to release, use or disclose my protected health informa$on.  
 
 
Pa$ents Name: _________________________________ 
 I affirm that I am the personal representa$ve of the pa$ent noted above and that I have the authority to 
authorize the release, use or disclosure of the pa$ent's protected health informa$on on his/her behalf. I 
have read the contents of this Authoriza$on, and I confirm that the contents are consistent with my 
direc$ons. I understand that by signing this form, I am authorizing, on behalf of the pa$ent, the release, 
use or disclosure the pa$ent's protected health informa$on.  
 
 
 Signature: ________________________________________        Date: ________________ 
 
 
                                                                                
Pediatric Den,stry Informed Consent for Pa,ent Management Techniques   
Please read carefully and feel free to ask ques2ons. We will be happy to explain it further.  It is our intent that our 
dental. care delivery be the best available. We are highly experienced in helping children overcome anxiety and we 
ask that you allow your child to accompany us through the dental experience. Dental anxiety is not uncommon in 
children so please try not to be concerned if your child exhibits some nega2ve behavior: this is normal and will 
soon lessen with 2me. Studies and experience have shown that most children react more posi2vely when 
permiBed to experience the dental visit in an environment designed for children.  Every effort will be made to 
obtain your child's coopera2on through warmth, charm, humor, and understanding. When these fail, there are 
several behavior management techniques our office uses to minimize disrup2ve behavior.  
The techniques used are recommended by the American Academy of Pediatric Den7stry and are described below.   
*Tell-Show-Do: The den2st or assistant first explains to the child what is to be done, then demonstrates on a model 
or on the child's finger. Finally, the procedure is completed on the pa2ent’s tooth. Praise is used to reinforce 
coopera2ve behavior.   
*Posi,ve Reinforcement: This technique rewards the child who displays any desirable behavior.  The rewards 
include compliments, praise, or a prize.   
*Voice Control: The aBen2on of a disrup2ve child is gained by changing the tone, increasing, or decreasing the 
volume of the prac22oner's voice.   
*Mouth Props: A rubber device is gently placed in the child's mouth to prevent either inten2onal or uninten2onal 
closure on the den2st's fingers or drill.   
*Touch and Go by Den,st/Assistant: Our assistants ask the child to hold their hand to prevent from grabbing a 
moving drill or a sharp object. They are not able to grab the prac22oner's hand while delicate work is being 
performed. This is for the safety of the child and to facilitate treatment.   
The following will be used AFTER obtaining consent from the parent/guardian   
• Laughing gas: Nitrous oxide (Laughing gas) is administered to calm and sooth the pa2ent prior to a dental 
procedure. Nitrous oxide is a very safe medica2on that on a rare occasion may cause nausea. We ask that your 
child not eat four hours prior to the nitrous oxide procedure.   
• Protec,ve Immobiliza,on: This is an immobilizing device (papoose) to limit the pa2ent’s disrup2ve movements 
and to prevent injury. It is used only as a last resort when treatment cannot be accomplished in any other way.  
The above listed pediatric den2stry behavior management techniques have been explained to me. I understand 
their use, and the risks benefits/alterna2ves available. I have had all my ques2ons answered and I realize I can 
always seek further informa2on or revoke permission for any of these techniques.  
 
 Signature:  __________________________________________________  Date: _________________________ 
ACKNOWLEDGEMENT OF RECEIPT: I acknowledge that I received a copy of the Pa2ent management consent. 
The Loose Tooth Pediatric Den1stry and Aligned Orthodon1cs 
 
No1ce of Privacy Prac1ces 
 
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.  
I. Dental Prac?ce Covered by this No?ce  
This No?ce describes the privacy prac?ces of The Loose Tooth Pediatric Den?stry and Aligned 
Orthodon?cs ("Dental Prac?ce"). "We" and "our" means the Dental Prac?ce. "You" and "your" means 
our pa?ent.  
II. How to Contact Us/Our Privacy Official  
If you have any ques?ons or would like further informa?on about this No?ce, you can contact Privacy 
Official at:  
 
The Loose Tooth Pediatric Den1stry and Aligned Orthodon1cs 
15041 S Van Dyke Rd Suite 105 
Plainfield, IL 
815-267-7299 
815-267-7511 
[email protected] 
 
 III. Our Promise to You and Our Legal Obliga?ons  
The privacy of your health informa?on is important to us. We understand that your health informa?on is 
personal and we are commiced to protec?ng it. This No?ce describes how we may use and disclose your 
protected health informa?on to carry out treatment, payment or health care opera?ons and for other 
purposes that are permiced or required by law. It also describes your rights to access and control your 
protected health informa?on. Protected health informa?on is informa?on about you, including 
demographic informa?on, that may iden?fy you and that relates to your past, present or future physical 
or mental health or condi?on and related health care services.  
We are required by law to:  
• Maintain the privacy of your protected health informa?on;  
• Give you this No?ce of our legal du?es and privacy prac?ces with respect to that informa?on; 
and  
• Abide by the terms of our No?ce that is currently in effect.  
V. How We May Use or Disclose Your Health Informa?on  
The following examples describe different ways we may use or disclose your health informa?on. These 
examples are not meant to be exhaus?ve. We are permiced by law to use and disclose your health 
informa?on for the following purposes:  
A. Common Uses and Disclosures  
1. Treatment. We may use your health informa?on to provide you with dental treatment or services, 
such as cleaning or examining your teeth or performing dental procedures. We may disclose health 
informa?on about you to dental specialists, physicians, or other health care professionals involved in 
your care.  
2. Payment. We may use and disclose your health informa?on to obtain payment from health plans and 
insurers for the care that we provide to you.  
3. Health Care Opera?ons. We may use and disclose health informa?on about you in connec?on with 
health care opera?ons necessary to run our prac?ce, including review of our treatment and services, 
training, evalua?ng the performance of our staff and health care professionals, quality assurance, 
financial or billing audits, legal macers, and business planning and development.  
4. Appointment Reminders. We may use or disclose your health informa?on when contac?ng you to 
remind you of a dental appointment. We may contact you by using a postcard, lecer, phone call, voice 
message, text or email.  
5. Treatment Alterna?ves and Health-Related Benefits and Services. We may use and disclose your 
health informa?on to tell you about treatment op?ons or alterna?ves or health-related benefits and 
services that may be of interest to you.  
6. Disclosure to Family Members and Friends. We may disclose your health informa?on to a family 
member or friend who is involved with your care or payment for your care if you do not object or, if you 
are not present, we believe it is in your best interest to do so.  
7. Disclosure to Business Associates. We may disclose your protected health informa?on to our third-
party service providers (called, "business associates") that perform func?ons on our behalf or provide us 
with services if the informa?on is necessary for such func?ons or services. For example, we may use a 
business associate to assist us in maintaining our prac?ce management sojware. All of our business 
associates are obligated, under contract with us, to protect the privacy of your informa?on and are not 
allowed to use or disclose any informa?on other than as specified in our contract.  
B. Less Common Uses and Disclosures   
1. Disclosures Required by Law. We may use or disclose pa?ent health informa?on to the extent we are 
required by law to do so. For example, we are required to disclose pa?ent health informa?on to the U.S. 
Department of Health and Human Services so that it can inves?gate complaints or determine our 
compliance with HIPAA.  
2. Public Health Ac?vi?es. We may disclose pa?ent health informa?on for public health ac?vi?es and 
purposes, which include: preven?ng or controlling disease, injury or disability; repor?ng births or deaths; 
repor?ng child abuse or neglect; repor?ng adverse reac?ons to medica?ons or foods; repor?ng product 
defects; enabling product recalls; and no?fying a person who may have been exposed to a disease or 
may be at risk for contrac?ng or spreading a disease or condi?on.  
3. Vic?ms of Abuse, Neglect or Domes?c Violence. We may disclose health informa?on to the 
appropriate government authority about a pa?ent whom we believe is a vic?m of abuse, neglect or 
domes?c violence.   
4. Health Oversight Ac?vi?es. We may disclose pa?ent health informa?on to a health oversight agency 
for ac?vi?es necessary for the government to provide appropriate oversight of the health care system, 
certain government benefit programs, and compliance with certain civil rights laws.  
5. Lawsuits and Legal Ac?ons. We may disclose pa?ent health informa?on in response to (i) a court or 
administra?ve order or (ii) a subpoena, discovery request, or other lawful process that is not ordered by 
a court if efforts have been made to no?fy the pa?ent or to obtain an order protec?ng the informa?on 
requested.  
6. Law Enforcement Purposes. We may disclose your health informa?on to a law enforcement official for 
a law enforcement purposes, such as to iden?fy or locate a suspect, material witness or missing person 
or to alert law enforcement of a crime.  
7. Coroners, Medical Examiners and Funeral Directors. We may disclose your health informa?on to a 
coroner, medical examiner or funeral director to allow them to carry out their du?es.  
8. Organ, Eye and Tissue Dona?on. We may use or disclose your health informa?on to organ 
procurement organiza?ons or others that obtain, bank or transplant cadaveric organs, eyes or ?ssue for 
dona?on and transplant.  
9. Research Purposes. We may use or disclose your informa?on for research purposes pursuant to 
pa?ent authoriza?on waiver approval by an Ins?tu?onal Review Board or Privacy Board.  
10. Serious Threat to Health or Safety. We may use or disclose your health informa?on if we believe it is 
necessary to do so to prevent or lessen a serious threat to anyone's health or safety.   
11. Specialized Government Func?ons. We may disclose your health informa?on to the military 
(domes?c or foreign) about its members or veterans, for na?onal security and protec?ve services for the 
President or other heads of state, to the government for security clearance reviews, and to a jail or 
prison about its inmates.   
12. Workers' Compensa?on. We may disclose your health informa?on to comply with workers' 
compensa?on laws or similar programs that provide benefits for work-related injuries or illness.  
VI. Your Wricen Authoriza?on for Any Other Use or Disclosure of Your Health Informa?on  
Uses and disclosures of your protected health informa?on that involve the release of psychotherapy 
notes (if any), marke?ng, sale of your protected health informa?on, or other uses or disclosures not 
described in this no?ce will be made only with your wricen authoriza?on, unless otherwise permiced or 
required by law. You may revoke this authoriza?on at any ?me, in wri?ng, except to the extent that this 
office has taken an ac?on in reliance on the use of disclosure indicated in the authoriza?on. If a use or 
disclosure of protected health informa?on described 
above in this no?ce is prohibited or materially limited by other laws that apply to use, we intend to meet 
the requirements of the more stringent law.  
VII. Your Rights with Respect to Your Health Informa?on  
You have the following rights with respect to certain health informa?on that we have about you 
(informa?on in a Designated Record Set as defined by HIPAA). To exercise any of these rights, you must 
submit a wricen request to our Privacy Official listed on the first page of this No?ce.  
A. Right to Access and Review   
You may request to access and review a copy of your health informa?on. We may deny your request 
under certain circumstances. You will receive wricen no?ce of a denial and can appeal it. We will provide 
a copy of your health informa?on in a format you request if it is readily producible. If not readily 
producible, we will provide it in a hard copy format or other format that is mutually agreeable. If your 
health informa?on is included in an Electronic Health Record, you have the right to obtain a copy of it in 
an electronic format and to direct us to send it to the person or en?ty you designate in an electronic 
format. We may charge a reasonable fee to cover our cost to provide you with copies of your health 
informa?on.  
B. Right to Amend  
If you believe that your health informa?on is incorrect or incomplete, you may request that we amend it. 
We may deny your request under certain circumstances. You will receive wricen no?ce of a denial and 
can file a statement of disagreement that will be included with your health informa?on that you believe 
is incorrect or incomplete.  
C. Right to Restrict Use and Disclosure  
You may request that we restrict uses of your health informa?on to carry out treatment, payment, or 
health care opera?ons or to your family member or friend involved in your care or the payment for your 
care. We may not (and are not required to) agree to your requested restric?ons, with one excep?on: If 
you pay out of your pocket in full for a service you receive from us and you request that we not submit 
the claim for this service to your health insurer or health plan for reimbursement, we must honor that 
request.  
D. Right to Confiden?al Communica?ons, Alterna?ve Means and Loca?ons  
You may request to receive communica?ons of health informa?on by alterna?ve means or at an 
alterna?ve loca?on. We will accommodate a request if it is reasonable and you indicate that 
communica?on by regular means could endanger you. When you submit a wricen request to the Privacy 
Official listed on the first page of this No?ce, you need to provide an alterna?ve method of contact or 
alterna?ve address and indicate how payment for services will be handled.  
E. Right to an Accoun?ng of Disclosures  
You have a right to receive an accoun?ng of disclosures of your health informa?on for the six (6) years 
prior to the date that the accoun?ng is requested except for disclosures to carry out treatment, 
payment, health care opera?ons (and certain other excep?ons as provided by HIPAA). The first 
accoun?ng we provide in any 12-month period will be without charge to you. We may 
charge a reasonable fee to cover the cost for each subsequent request for an accoun?ng within the same 
12-month period. We will no?fy you in advance of this fee and you may choose to modify or withdraw 
your request at that ?me.  
F. Right to a Paper Copy of this No?ce  
You have the right to a paper copy of this No?ce. You may ask us to give you a paper copy of the No?ce 
at any ?me (even if you have agreed to receive the No?ce electronically). To obtain a paper copy, ask the 
Privacy Official.  
G. Right to Receive No?fica?on of a Security Breach  
We are required by law to no?fy you if the privacy or security of your health informa?on has been 
breached. The no?fica?on will occur by first class mail within sixty (60) days of the event. A breach 
occurs when there has been an unauthorized use or disclosure under HIPAA that compromises the 
privacy or security of your health informa?on.  
The breach no?fica?on will contain the following informa?on: (1) a brief descrip?on of what happened, 
including the date of the breach and the date of the discovery of the breach; (2) the steps you should 
take to protect yourself from poten?al harm resul?ng from the breach; and (3) a brief descrip?on of 
what we are doing to inves?gate the breach, mi?gate losses, and to protect against further breaches.  
VIII. Special Protec?ons for HIV, Alcohol and Substance Abuse, Mental Health and Gene?c Informa?on  
Certain federal and state laws may require special privacy protec?ons that restrict the use and disclosure 
of certain health informa?on, including HIV-related informa?on, alcohol and substance abuse 
informa?on, mental health informa?on, and gene?c informa?on. For example, a health plan is not 
permiced to use or disclose gene?c informa?on for underwri?ng purposes. Some parts of this HIPAA 
No?ce of Privacy Prac?ces may not apply to these types of informa?on. If your treatment involves this 
informa?on, you may contact our office for more informa?on about these protec?ons.  
IX. Our Right to Change Our Privacy Prac?ces and This No?ce  
We reserve the right to change the terms of this No?ce at any ?me.  Any change will apply to the health 
informa?on we have about you or create or receive in the future. We will promptly revise the No?ce 
when there is a material change to the uses or disclosures, individual's rights, our legal du?es, or other 
privacy prac?ces discussed in this No?ce. We will post the revised No?ce on our website (if applicable) 
and in our office and will provide a copy of it to you on request. The effec?ve date of this No?ce is 
September 7, 2014  
X. How to Make Privacy Complaints  
If you have any complaints about your privacy rights or how your health informa?on has been used or 
disclosed, you may file a complaint with us by contac?ng our Privacy Official listed on the first page of 
this No?ce.  
You may also file a wricen complaint with the Secretary of the U.S. Department of Health and Human 
Services, Office for Civil Rights. We will not retaliate against you in any way if you choose to file a 
complaint. 
 
 
Signature: ____________________________________________      Date:_______________