Sample New Patient Questionnaire - Iowa Central Community College

Patient Information (Please complete in ink)Patient Name: _________________________________________________________ Date:_______________Last First MIMale Female Married Single Child Other _____________Social Security #: ________________________________ ICCC ID # (if an Iowa Central Student) ____________Birth Date: _________________________________Phone (with area code) (Home): ______________ (Work): ______________ Ext:______ (Cell): _____________Address: _________________________________________________________________________________Street City State Zip CodeEmail: ____________________________________________________________________________________Emergency Contact: (Name) ____________________________________ (Phone) ______________________Ethnicity (optional): White, Non-Hispanic Hispanic American Indian/Alaskan NativeAfrican-American Asian/Pacific Islander Other ______________________________Health InformationDate of Last Dental Visit: __________________ Reason for this visit:_________________________________________If you would like a copy of today’s x-rays sent to your dentist, please provide his/her name and address:Dentist’s name:_______________________________ Address:_____________________________________________Have you ever had any of the following? Please check those that apply:AlcoholismAllergies ____________________AnemiaArthritisArtificial Heart ValveArtificial JointsAsthmaBlood DiseaseCancerChemotherapyCortisone MedicationDiabetesDizzinessDry MouthEating DisorderEmphysemaEpilepsyExcessive BleedingFaintingGlaucomaGrowthsHay FeverHead InjuriesHeart DiseaseHeart MurmurHeart SurgeryHepatitisHigh Blood PressureHIV/AIDSJaundiceJaw PainKidney DiseaseLiver DiseaseMental DisordersNervous DisordersPacemakerPregnancy (currently)Due date:_________Previous InfectiveEndocarditisRecreationalDrugs/CocaineRadiation TreatmentRespiratory ProblemsRheumatic FeverRheumatismSexually TransmittedDisease (STD)Sinus ProblemsStomach ProblemsStrokeTuberculosisTumorsUlcersCodeine AllergyPenicillin AllergyLatex AllergyOTHER:Please list any medications you are now taking:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________• Do you use tobacco products? Yes No If yes, what kind and how much? __________________Are you interested in quitting? (Circle one) Very Somewhat Not interested• Have you ever had to be pre-medicated for dental treatment? Yes No• Have you ever had any complications following dental treatment? Yes NoIf yes, please explain:_______________________________________________________________________• Have you been admitted to a hospital or needed emergency care during the past two years? Yes NoIf yes, please explain:______________________________________________________________________• Are you now under the care of a physician? Yes NoIf yes, please explain:______________________________________________________________________• Name of Physician:___________________________________________ Phone:______________________• Do you have any health problems that need further clarification? Yes NoIf yes, please explain:______________________________________________________________________***********************************************************************************************************************************************************************************************************************************I have reviewed the Health History and give permission for treatment to be completed by the Dental Hygienestudent_________________________________________________________________ Date: ___________________Signature of Clinic Dentist

Responsible Party Information(Complete this section if patient is under 18 or someone other than the patient is responsible for payment)The following is for: the patient's spouse the person responsible for payment the patient’s parent/guardianName:Male Female Married Single Child OtherSocial Security #: ________________________________Birth Date: ______________________________Phone – with area code (Home): ________________ (Work): ________________ Ext:______ (Cell):Mailing Address:Street City State Zip CodeInsurance InformationName of Insured: _______________________________________________ Is insured a patient? Yes NoLast First MIInsured's Birth Date: _________________ ID #: _____________________ Group #:Insured's Address:Street City State Zip CodeInsured's Employer Name and AddressPatient's relationship to insured: Self Spouse Child Other___________________Insurance Plan Name:_______________________________________________________________________Address:Street City State Zip CodeDental Insurance: It is your responsibility to consult with your insurance company for details on your covered or non-covered services, servicelimitations or restrictions, and yearly maximums. Medical coverage does not pay for dental hygiene services. You will receive a “super bill” that you cansend in for reimbursement from your insurance company.Consent for ServicesAs a condition of your treatment by the Iowa Central Community College Dental Hygiene Student Clinic, financial arrangements must be made inadvance. The clinic depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of eachpatient must be determined before treatment. Payment for dental hygiene treatment is required at each visit. We accept cash, check, and credit cardsfor payment of services.Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personallyresponsible for payment of all dental services. The Iowa Central Community College Dental Hygiene Student Clinic will help prepare the patientsinsurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, thisDental Hygiene clinic cannot render services on the assumption that our charges will be paid by an insurance company.I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of saidservices to said Doctor, or his assignee, at the time said services are rendered. I further agree that a waiver of any breach of any time or conditionhereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit beinstituted hereunder.I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.I have read the above conditions of treatment and payment and agree to their content.To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I everhave any change in my health, I will inform the clinic at the next appointment without fail.I am able to read and speak English.I have received a copy of the privacy practices of the Iowa Central Dental Hygiene Clinic.____________________________________________________Signature of patient, parent or guardian, or guarantor of paymentDate: __________Relationship to Patient:

Iowa Central Community CollegeDental Hygiene Student ClinicThis is a teaching clinic. All treatment is provided by dental hygiene students. Dental hygiene studentsare supervised by licensed dental hygiene faculty and a licensed dentist. Services performed are limitedto preventive treatment and not intended to take the place of restorative dental treatment. Our teachingclinics strive to provide the best care for you; however there are some treatments that our studentscannot provide. You may need to see a private dental office for further treatment.Fees will be charged for all dental hygiene services performed, however, they are greatly reduced fromthose in private practices, and payment is due at time of service. You will be responsible for paying thecosts of the dental hygiene services provided.Payment must be submitted at each appointment for the treatment received. The clinic will accept cash,check, debit or credit card.If you have dental insurance coverage, you will be given a form to submit to your insurance companyfor reimbursement.Please be aware that your dental insurance may not reimburse you for all your treatment costs.Unattended children are not allowed in the reception area. Persons who are not patients are not allowedon the clinic floor. This may be waived if there are extenuating circumstances.Patient EligibilityIowa Central Community College Dental Hygiene Clinic is an educational institution and providespreventative and oral hygiene patient treatment. In general, all persons who are able to afford the timeand the cost will be treated at the school. Furthermore, patients whose medical or emotionalmanagement would be beyond the ability of the student in a school setting may not be accepted fortreatment.New PatientsAppointments for new patients for consultations, radiographs, or hygiene services are usuallyscheduled by the Dental Hygiene student. Appointments may be scheduled by contacting the clinicreceptionist.Patient Assignment ProceduresAll patients are screened by the student and faculty and categorized according to the complexity oftheir dental hygiene needs. Student assignment may be made by the clinic instructors and is closelylinked to the need of providing appropriate clinical experience to students based on their need toachieve and maintain clinical competency.Last modified 08-28-09

ProceduresThe following is a list of dental hygiene services and functions taught to clinical competency andperformed by dental hygiene students in the Dental Hygiene Clinic. Treatment is prescribed bylicensed dentists employed by the college to supervise clinic sessions. Licensed dental hygienists areemployed in the clinic to instruct, evaluate, and enhance the students’ clinical learning experiences.1. Clinical infection control procedures2. Social, medical and dental history data collection3. Blood pressure and pulse measurements, temperature and respiration rates4. Extra-oral and intraoral examinations (Cancer Screening)5. Dental charting6. Periodontal charting and assessment7. Patient oral health education8. Dental hygiene assessment, treatment planning, and evaluation9. Oral radiographs – exposing, processing and interpreting• Bitewing x-ray• Full mouth x-rays• Panographic x-rays10. Calculus detection11. Ultrasonic scaling12. Periodontal scaling13. Root (planing) debridement14. Polishing15. Application of topical fluoride16. Application of dental sealants17. Application of tooth desensitization18. Application of topical anesthetic agents, including transoral delivery system19. Local anesthesia as needed20. Removal of interproximal overhangs21. Application of chemotherapeutic agents including subgingival irrigation22. Nutritional counseling23. Alginate impressions and study models24. Cleaning of removable prosthetic appliancesThe following procedures are taught to laboratory competency*1. Placement and removal of rubber dams2. Maintenance of dental implants3. Finishing and polishing amalgam restorations4. Suture removal5. Pulp vitality6. Placement and removal of periodontal dressings7. Soft tissue curettage*Procedures taught to laboratory competence are delegable to a licensed dental hygienist in the state of Iowa by a licensed dentist. The theory and processpertaining to these procedures are presented to students in dental hygiene courses. Students practice the procedures on student partners or manikins underdirect faculty supervision. These procedures may be prescribed and provided to a community patient when such need has been determined during theassessment process; however, since adequate pool of patients is not always available, students are not required to achieve clinic competence prior tograduation.Last modified 08-28-09

NOTICE OF PRIVACY PRACTICESTHIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSEDAND HOW YOU CAN GET ACCESS TO THIS INFORMATION.PLEASE REVIEW THIS NOTICE CAREFULLY.Each time you visit the Iowa Central Community College Dental Clinic, a record of your visit is made.This record includes information about your symptoms, examinations, medications you take, yourallergies, your medical and dental histories and the plan for your care. This information we refer to asyour health or dental record and is an essential part of the dental care we provide for you. Your dentalrecord contains personal health information and there are state and federal laws to protect the privacyof your health information.In this notice we will tell you how we may use and disclose protected health information about you.Protected health information means any health information about you that could identify you (forexample, your date of birth or social security number). In this notice, we will refer to protected healthinformation as your health information.This notice will tell you about our privacy practices in accordance with the laws and will tell youabout your rights and duties in regard to your health information. Also, it will describe how youcan complain to us if you think we have violated your privacy rights.We are required by law to:a. maintain the privacy of your health information;b. provide you with notice of our legal duties and privacy practices; andc. abide by the terms of this Notice of Privacy Practices.HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOUFor Treatment. All student dental hygienists, clinical staff, and supervisors involved in your care will readand document in your dental record about your examinations, the care plan for you, the care that you receivedand the results of that care. Your health information may be used and disclosed by those who are involved inyour care for the purpose of providing, coordinating, or managing services and supports. This includesconsultation with supervisors or other team members.If you were referred to us by another provider, your Iowa Central Community College Dental Clinic providermay send copies of your dental record to the provider who referred you to us so your provider will have updatedtreatment information about your care. We may share or disclose your health information with other health careproviders so that the services you receive related to your health will be able to work together. For example, wemay refer you to professionals for services we cannot provide so as to obtain new services for you. When we dothis we need to tell them about you and your needs.We may also use information from your dental record to call you or send you a letter or postcard to remind youabout an appointment, to follow up with diagnostic test results, to advise you of your treatment status, or toprovide you with information about treatment and care that can benefit your health.For Payment. We may use and disclose health information about you so that we can receive payment for theservices we provide to you. Examples of such activities are billing a third party payor, such as Medicaid or yourinsurance company. We may need, for example, to provide the Medicaid program with information about theservices we provide to you so that we will be paid for those services. Also, we may need to provide theMedicaid program with information to make sure you are eligible for the medical assistance program.Last modified 08-28-09

For Health Care Operations. There are a few other ways we may use or disclose your health information forwhat are called health care operations. For example, we may use your health information to see where we canmake improvements in the services we provide. We may use the information to explore ways to moreefficiently manage our business, for licensing or accreditation activities, or for our compliance program.Iowa Central Community College Dental Clinic is a teaching facility so it is also probable that we will useyour dental record in the process of educating and training students.You have the right to request a restriction on the above uses and disclosures of your protected healthinformation for treatment, payment and health care operations; however, we are not required to agree to yourrequest. If we do agree, we will comply with your request unless the information is needed to provide youemergency treatment. We may, however, also end the agreement at any time after informing you of such.OTHER USES AND DISCLOSURES OF YOUR HEALTH INFORMATIONDisclosures to individuals involved in your care or payment for your care: We may disclose to aguardian/parent, personal representative, family member, or any other person identified by you, healthinformation that is relevant to that person’s involvement with the support s and service s you receive orpayment for that service and support. For example, if there is a health emergency, we may need to notifyone of the above identified persons of your health situation. If there is a family member or other relativethat you do not want us to disclose health information about you, please notify us via mail Renee Piper 303Avenue M, Fort Dodge Iowa 50501Verbal Permission: We may use or disclose your information to family members that are directly involved inyour treatment with your verbal permission.Appointment Reminders: We may use and disclose health information to reschedule or remind you ofappointments or meetings regarding your treatment.How We Will Contact You: If you want us to call or write to you only at your home or work or prefersome other way to reach you, we can usually arrange that. If you want to request that we communicatewith you in a certain way or at a certain place, see “Right to Request Confidential Communications” in thisNotice. Unless you tell us otherwise, we may contact you either by telephone or by mail at either yourhome or work. At either location, we may leave messages for you on the answering machine or voice mailconcerning health information.Treatment and Service Alternatives: We may use or disclose your health information to tell you about orsuggest possible treatments or services that may be of interest to you.Business Associates: Certain aspects and components of our services are performed through contracts withoutside persons or organizations, such as auditing, accreditation, legal services, etc. At times it may benecessary for us to provide certain of your personal health information to one or more of these outsidepersons or organizations who assist us with our payment/billing activities and health care operations. Insuch cases, we require these business associates to appropriately safeguard the privacy of your information.Public Health: We may disclose health information about you for public health activities. These activitiesmay include disclosuresa. to a public health authority authorized by law to collect or receive such information for the purposeof preventing or controlling disease, injury, or disability;b. to appropriate authorities to receive reports of abuse and neglect;c. to FDA-regulated entities for purposes of monitoring or reporting the quality, safety, oreffectiveness of FDA-regulated products; orLast modified 08-28-09

d. to notify a person who may have been exposed to a disease or may be at risk for contracting orspreading a disease or condition.For Law Enforcement Purposes: We may disclose health information about you to a law enforcementofficial as required by law, in response to a court, grand jury or administrative order, subpoena or warrant.We may also disclose health information to identify or locate a suspect, material witness, missing person orfugitive or about an actual or suspected crime victim if that person agrees to the disclosure. In limitedcircumstances, if we are unable to obtain that person’s agreement the information may still be disclosed.Threats to Health or Safety: We may use or disclose protected health information about you if we believethe disclosure or use is necessary to prevent or lessen an imminent or serious threat to the health or safetyof a person or the public. We may also release information if we believe it is necessary for law enforcementto apprehend or identify a person who admitted participation in a violent crime or who is an escapee from acorrectional institution or from lawful custody.Community Health Center Fort Dodge: Because Iowa Central Dental Hygiene and Community HealthCenter Fort Dodge share an electronic record keeping system, your health information may be accessed byCHCFD employees for healthcare purposes.For Specific Government Functions: We may disclose the health information of military personnel andveterans to government benefit programs relating to eligibility and enrollment. We may disclose yourhealth information to Worker’s Compensation and Disability programs, to correctional facilities if you arean inmate, and for national security reasons.We will not use information in your records for marketing purposes.Other uses and disclosures from your dental record will be made only with your written authorization orapproval.YOUR RIGHTS REGARDING YOUR HEALTH INFORMATIONYou have the following rights regarding the health information we maintain about you. To exercise any of theserights, please submit your request in writing to us via mail, Renee Piper 303 Avenue M, Fort Dodge Iowa50501 or via phone at (800) 362-2793 ext.2335, or tell the student who is providing services to you and thestudent will provide to you a form for you to record your request.• Right of Access to Inspect and Copy Your Dental Records. You have the right, which may berestricted only in exceptional circumstances, to inspect and copy health information that may be used tomake decisions about your care. Your right to inspect and copy health information will be restrictedonly in those situations where there is compelling evidence that access would cause serious harm to you.We may charge a reasonable, cost-based fee for copies. We will act on your request within thirty (30)calendar days after we receive your written request. If we deny the request, we will inform you of thereasons for the denial in writing, how you can have the denial reviewed, and how you may complain.• Right to Request an Amendment to Your Dental Records. If you feel that the health information wehave about you is incorrect or incomplete, you may ask us in writing to amend the information althoughwe are not required to agree to the amendment. We will act on your request within 60 (sixty) calendardays after we receive your request.• Right to an Accounting of Disclosures. You have the right to request in writing an accounting ofcertain of the disclosures that we make of your health information. This accounting may be for up to sixyears prior to the date on which you request the accounting but not before April 14, 2003. We mayLast modified 08-28-09

charge you a reasonable fee if you request more than one accounting in any 12-month period. We willact on your request within sixty (60) calendar days after we receive your request.• Right to Request Restrictions on Use or Disclosure of Your Health Information. You have theright to request in writing a restriction or limitation on the use or disclosure of your health informationfor treatment, payment, or health care operations at any time. You also have the right to request that werestrict the use s or disclosure s we make to a family member or any other person you identify or topublic/private entities for disaster relief. For example, you could ask that we not disclose yourinformation to your sister or brother. We are not required to agree to any requested restriction.• Right to Request Confidential Communication. You have the right to request that we communicatewith you about health matters in a certain way or at a certain location. For example, you may ask thatwe only contact you at home or by mail. You do not have to tell us why you are choosing this way ofcommunicating confidential information. We may require an alternate method or address to contactyou.• Right to a Copy of this Notice. You have the right to a paper copy of this Notice of Privacy Practices.To obtain a paper copy of this notice, please let us know.• The Dental Hygiene Program is in compliance with the Iowa Dental Practice Act, Occupational SafetyHazards Act (OSHA) and Center for Disease Control and Prevention (CDC), universal precautions andguidelines for preventing transmission of blood-borne pathogens as well as hazards control measures.There is potential risk even utilization of the above control measures.Iowa Central Community College reserves the right to change this Notice of Privacy Practices and itspolicies and procedures for privacy practices at any time and to make the changes effective for allprotected health information created or received prior to the new effective date and then currentlymaintained by Iowa Central Community College’s Dental Clinic. The revised Notice will be posted in theCollege’s Dental Clinic lobby. You may also obtain a copy of the revised Notice from the Dental Clinicoffice.COMPLAINTSIf you believe we have violated your privacy rights, you have the right to file a complaint in writing with us.To file a complaint, contact us via mail Renee Piper 303 Avenue M, Fort Dodge Iowa 50501 or via phone at(800) 362-2793 ext. 2335. You may complain to the Secretary of Health and Human Services at 200Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257.You will not be retaliated against or treated differently for filing a complaint.If you have questions or problems:If you need more information or have questions about the privacy practices described above, please contactRenee Piper, 303 Avenue M, Fort Dodge Iowa 50501 or via phone at (800) 362-2793 ext. 2335.Effective Date: August 1, 2006Last modified 08-28-09

Consent for Use and Disclosure of Health InformationPurpose: To obtain a client’s consent to use and disclosure of the client’s protected health information to carry outtreatment, payment activities, and healthcare operations, as described more fully in Iowa Central CommunityCollege’s Notice of Privacy Practices.Client’s Name: ______________________________________________________________Address: ___________________________________________________________________Telephone: _______________________Social Security Number: ___________________Purpose of Consent: By signing this form, you will consent to our use and disclosure of pour protected healthinformation to carry out treatment, payment activities, and health care operations.Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whetherto sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcareoperations, of the uses and disclosures we may make of your protected health information, and of other importantmatters about your protected health information. A copy of our Notice accompanies this Consent. We encourage youto read it carefully and completely before signing this Consent.We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we changeour privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Thosechanges may apply to any of your protected health information that we maintain.You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time bycontacting: Iowa Central Dental Hygiene Clinic, One Triton Circle, Fort Dodge, Iowa 50501, 1-800-362-2793,extension 1327.Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of yourrevocation submitted to the contact information listed above. Please understand that revocation of this Consent willnot affect any action we took in reliance on this Consent before we received your revocation, and that we maydecline to treat you or to continue treating you if you revoke this Consent.I have had full opportunity to read and consider the contents of this Consent form and your Notice of PrivacyPractices. I understand that by, by signing this Consent form, I am giving my consent to your use and disclosure ofmy protected health information to carry out treatment, payment activities and health care operations.Client’s Signature: __________________________________________Date: _____________If the Consent is signed by a personal representative on behalf of the client, complete thefollowing:Personal Representative’s Name: __________________________________________________Relationship to Client: __________________________________________________________YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT