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P L E A S E P R I N T
INSURANCE AND FINANCIAL INFORMATION
ASSIGNMENT & RELEASE
I N S U R A N C E COV E R AG E
S ECO N DA RY COV E R AG E
YES
SELF
SELF
SPOUSE
SPOUSE
DEPENDENT
DEPENDENT
YES
INSURANCE COMPANY NAME
INSURANCE COMPANY NAME
SUBSCRIBER’S NAME
SUBSCRIBER’S NAME
GROUP / PROGRAM NUMBER
GROUP / PROGRAM NUMBER
^/'EdhZͳPATIENT / GUARDIAN
WITNESS SIGNATURE DATE
DATE
EMPLOYER Έ/&/&&ZEd&ZKDKsΉ
EMPLOYER Έ/&/&&ZEd&ZKDKsΉ
SUBSCRIBER’S BIRTHDAY
SUBSCRIBER’S BIRTHDAY
EMPLOYER’S ADDRESS
EMPLOYER’S ADDRESS
SUBSCRIBER’S SSN / ID #
SUBSCRIBER’S SSN / ID #
INSURANCE ADDRESS
PATIENT’S RELATIONSHIP TO SUBSCRIBER
PATIENT’S RELATIONSHIP TO SUBSCRIBER
INSURANCE ADDRESS
INSURANCE PHONE
INSURANCE PHONE
NO
NO
/ŚĞƌĞďLJĂƵƚŚŽƌŝnjĞŵLJŝŶƐƵƌĂŶĐĞďĞŶĞĮƚƐƚŽďĞƉĂŝĚĚŝƌĞĐƚůLJƚŽƚŚĞĚĞŶƟƐƚƐ/ĂŵĮŶĂŶĐŝĂůůLJƌĞƐƉŽŶƐŝďůĞĨŽƌĂŶLJďĂůĂŶĐĞƐĚƵĞĂŶĚĂƵƚŚŽƌŝnjĞƚŚĞĚĞŶƟƐƚƐƚŽƌĞůĞĂƐĞĂŶLJŝŶĨŽƌŵĂƟŽŶĨŽƌƚŚŝƐĐůĂŝŵ/ĂƵƚŚŽƌŝnjĞƚŚĂƚŵLJƌĞĐŽƌĚƐĐĂŶďĞƵƐĞĚďLJƚŚĞĚŽĐƚŽƌŝĨŚĞƐŽĚĞƚĞƌŵŝŶĞƐ/ŶĐŽŶƐŝĚĞƌĂƟŽŶŽĨƚŚĞƐĞƌǀŝĐĞƐƌĞŶĚĞƌĞĚƚŽŵĞďLJƚŚŝƐĚĞŶƚĂůŽĸĐĞ/ĂŵŽďůŝŐĂƚĞĚƚŽƉĂLJƐĂŝĚŽĸĐĞŝŶĂĐĐŽƌĚĂŶĐĞǁŝƚŚŝƚƐĐƌĞĚŝƚƚĞƌŵƐĂŶĚƉŽůŝĐLJ
/ĐŽŶƐĞŶƚƚŽŵĂŬŝŶŐŽĨǀŝĚĞŽƚĂƉĞƐƉŚŽƚŽŐƌĂƉŚƐĂŶĚdžͲƌĂLJƐďĞĨŽƌĞĚƵƌŝŶŐĂŶĚĂŌĞƌƚƌĞĂƚŵĞŶƚĂŶĚƚŽƵƐĞƚŚĞƐĂŵĞďLJƚŚĞĚŽĐƚŽƌŝŶƐĐŝĞŶƟĮĐƉĂƉĞƌƐŽƌĚĞŵŽŶƐƚƌĂƟŽŶƐ
/ĐĞƌƟĨLJƚŚĂƚ/ŚĂǀĞƌĞĂĚŽƌŚĂĚƌĞĂĚƚŽŵĞƚŚĞĐŽŶƚĞŶƚƐŽĨƚŚŝƐĨŽƌŵĂŶĚĚŽƌĞĂůŝnjĞƚŚĞƌŝƐŬƐĂŶĚůŝŵŝƚĂƟŽŶƐŝŶǀŽůǀĞĚ
RELEASE INFORMATION
CONFIRMATIONS
zKhDz/^h^^Dz,>d,Zt/d,
DO YOU PREFER A CONFIRMATION CALL
Kd,Z^ΈW>^WZ/EdΉYES NOHealth Care Providers
Insurance Companies
No, it is unnecessary zĞƐŝƚŝƐĂŚĞůƉĨƵůƌĞŵŝŶĚĞƌ
1.
2.
v2.0 - 2011 Kois Center, LLC To reorder, please visit: www.koiscenter.com
CONFIDENTIAL INFORMATION QUESTIONNAIRE
EMERGENCY CONTACT INFORMATION
REQUEST FOR CONFIDENTIAL COMMUNICATION
M A R I TA L STAT U SS
UNDER AGE 18
PATIENT’S LEGAL NAME LAST, FIRST MI
PREFER TO BE CALLED HOME PHONE # CELL PHONE #
ͳD/>
OCCUPATION
OCCUPATION
PATIENT’S / GUARDIAN’S EMPLOYER
WORK PHONE #
WORK PHONE #
WHO CAN WE THANK FOR REFERRING YOU TO OUR OFFICE?OTHER FAMILY MEMBERS THAT ARE PATIENTS HERE
SPOUSE’S EMPLOYER
DATE OF BIRTH
P L E A S E P R I N T
SOCIAL SECURITY #SEX
SPOUSE’S NAME LAST, FIRST MI
PATIENT’S ADDRESS STREET APT# CITY STATE ZIP
WORK ADDRESS STREET APT# CITY STATE ZIP
SPOUSE’S WORK ADDRESS STREET APT# CITY STATE ZIP
M W D
WZ^KEtDzKEdd/E^K&EDZ'EzΈKd,Zd,EzKhZ&D/>z,KDΉ
RELATIONSHIPNAME
HOME PHONE #
^DzEd>ZWZKs/ZzKhDzKd,&K>>Kt/E't/d,DzWZD/^^/KEYES NO
Contact me at home
Contact me via cell phone
Contact me at work
Contact me via e-mail
Leave messages on my home voicemail / answering machine
Leave messages on my cell phone voicemail
Leave messages on my work voicemail / answering machine
WORK PHONE # CELL PHONE #
v2.0 - 2011 Kois Center, LLC To reorder, please visit: www.koiscenter.com
EĂŵĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺEŝĐŬŶĂŵĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺŐĞͺͺͺͺͺͺͺͺͺZĞĨĞƌƌĞĚďLJͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ,ŽǁǁŽƵůĚLJŽƵƌĂƚĞƚŚĞĐŽŶĚŝƟŽŶŽĨLJŽƵƌŵŽƵƚŚdžĐĞůůĞŶƚ'ŽŽĚ&ĂŝƌWŽŽƌWƌĞǀŝŽƵƐĞŶƟƐƚͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ,ŽǁůŽŶŐŚĂǀĞLJŽƵďĞĞŶĂƉĂƟĞŶƚͺͺͺͺͺͺͺͺͺͺͺDŽŶƚŚƐzĞĂƌƐĂƚĞŽĨŵŽƐƚƌĞĐĞŶƚĚĞŶƚĂůĞdžĂŵͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺĂƚĞŽĨŵŽƐƚƌĞĐĞŶƚdžͲƌĂLJƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺĂƚĞŽĨŵŽƐƚƌĞĐĞŶƚƚƌĞĂƚŵĞŶƚ;ŽƚŚĞƌƚŚĂŶĂĐůĞĂŶŝŶŐͿͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ/ƌŽƵƟŶĞůLJƐĞĞŵLJĚĞŶƟƐƚĞǀĞƌLJϯŵŽϰŵŽϲŵŽϭϮŵŽEŽƚƌŽƵƟŶĞůLJ
WHAT IS YOUR IMMEDIATE CONCERN? ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ PLEASE ANSWER YES OR NO TO THE FOLLOWING: YES NO
ϭ ƌĞLJŽƵĨĞĂƌĨƵůŽĨĚĞŶƚĂůƚƌĞĂƚŵĞŶƚ ,ŽǁĨĞĂƌĨƵů ŽŶĂƐĐĂůĞŽĨϭ;ůĞĂƐƚͿƚŽϭϬ;ŵŽƐƚͿ ͺͺ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϮ ,ĂǀĞLJŽƵŚĂĚĂŶƵŶĨĂǀŽƌĂďůĞĚĞŶƚĂůĞdžƉĞƌŝĞŶĐĞ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϯ ,ĂǀĞLJŽƵĞǀĞƌŚĂĚĐŽŵƉůŝĐĂƚŝŽŶƐĨƌŽŵƉĂƐƚĚĞŶƚĂůƚƌĞĂƚŵĞŶƚ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϰ ,ĂǀĞLJŽƵĞǀĞƌŚĂĚƚƌŽƵďůĞŐĞƚƚŝŶŐŶƵŵďŽƌŚĂĚĂŶLJƌĞĂĐƚŝŽŶƐƚŽůŽĐĂůĂŶĞƐƚŚĞƚŝĐ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϱ ŝĚLJŽƵĞǀĞƌŚĂǀĞďƌĂĐĞƐ ŽƌƚŚŽĚŽŶƚŝĐƚƌĞĂƚŵĞŶƚŽƌŚĂĚLJŽƵƌďŝƚĞĂĚũƵƐƚĞĚ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϲ ,ĂǀĞLJŽƵŚĂĚĂŶLJƚĞĞƚŚƌĞŵŽǀĞĚ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
ϳ ŽLJŽƵƌŐƵŵƐďůĞĞĚŽƌĂƌĞƚŚĞLJƉĂŝŶĨƵůǁŚĞŶďƌƵƐŚŝŶŐŽƌĨůŽƐƐŝŶŐ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϴ ,ĂǀĞLJŽƵĞǀĞƌďĞĞŶƚƌĞĂƚĞĚĨŽƌŐƵŵĚŝƐĞĂƐĞŽƌďĞĞŶƚŽůĚLJŽƵŚĂǀĞůŽƐƚďŽŶĞĂƌŽƵŶĚLJŽƵƌƚĞĞƚŚ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϵ ,ĂǀĞLJŽƵĞǀĞƌŶŽƚŝĐĞĚĂŶƵŶƉůĞĂƐĂŶƚƚĂƐƚĞŽƌŽĚŽƌŝŶLJŽƵƌŵŽƵƚŚ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϭϬ /ƐƚŚĞƌĞĂŶLJŽŶĞǁŝƚŚĂŚŝƐƚŽƌLJŽĨƉĞƌŝŽĚŽŶƚĂůĚŝƐĞĂƐĞŝŶLJŽƵƌĨĂŵŝůLJ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϭϭ ,ĂǀĞLJŽƵĞǀĞƌĞdžƉĞƌŝĞŶĐĞĚŐƵŵƌĞĐĞƐƐŝŽŶ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϭϮ ,ĂǀĞLJŽƵĞǀĞƌŚĂĚĂŶLJƚĞĞƚŚďĞĐŽŵĞůŽŽƐĞŽŶƚŚĞŝƌŽǁŶ;ǁŝƚŚŽƵƚĂŶŝŶũƵƌLJͿ ŽƌĚŽLJŽƵŚĂǀĞĚŝĨĨŝĐƵůƚLJĞĂƚŝŶŐĂŶĂƉƉůĞ ͺͺͺͺͺͺͺͺͺͺͺͺϭϯ ,ĂǀĞLJŽƵĞdžƉĞƌŝĞŶĐĞĚĂďƵƌŶŝŶŐƐĞŶƐĂƚŝŽŶŝŶLJŽƵƌŵŽƵƚŚ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
ϭϰ ,ĂǀĞLJŽƵŚĂĚĂŶLJĐĂǀŝƚŝĞƐǁŝƚŚŝŶƚŚĞƉĂƐƚϯLJĞĂƌƐ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϭϱ ŽĞƐƚŚĞĂŵŽƵŶƚŽĨƐĂůŝǀĂŝŶLJŽƵƌŵŽƵƚŚƐĞĞŵƚŽŽůŝƚƚůĞŽƌĚŽLJŽƵŚĂǀĞĚŝĨĨŝĐƵůƚLJƐǁĂůůŽǁŝŶŐĂŶLJĨŽŽĚ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϭϲ ŽLJŽƵĨĞĞůŽƌŶŽƚŝĐĞĂŶLJŚŽůĞƐ;ŝ Ğ ƉŝƚƚŝŶŐ ĐƌĂƚĞƌƐͿŽŶƚŚĞďŝƚŝŶŐƐƵƌĨĂĐĞŽĨLJŽƵƌƚĞĞƚŚ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϭϳ ƌĞĂŶLJƚĞĞƚŚƐĞŶƐŝƚŝǀĞƚŽŚŽƚ ĐŽůĚ ďŝƚŝŶŐ ƐǁĞĞƚƐ ŽƌĂǀŽŝĚďƌƵƐŚŝŶŐĂŶLJƉĂƌƚŽĨLJŽƵƌŵŽƵƚŚ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϭϴ ŽLJŽƵŚĂǀĞŐƌŽŽǀĞƐŽƌŶŽƚĐŚĞƐŽŶLJŽƵƌƚĞĞƚŚŶĞĂƌƚŚĞŐƵŵůŝŶĞ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϭϵ ,ĂǀĞLJŽƵĞǀĞƌďƌŽŬĞŶƚĞĞƚŚ ĐŚŝƉƉĞĚƚĞĞƚŚ ŽƌŚĂĚĂƚŽŽƚŚĂĐŚĞŽƌĐƌĂĐŬĞĚĨŝůůŝŶŐ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϮϬ ŽLJŽƵĨƌĞƋƵĞŶƚůLJŐĞƚĨŽŽĚĐĂƵŐŚƚďĞƚǁĞĞŶĂŶLJƚĞĞƚŚ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
Ϯϭ ŽLJŽƵŚĂǀĞƉƌŽďůĞŵƐǁŝƚŚLJŽƵƌũĂǁũŽŝŶƚ ;ƉĂŝŶ ƐŽƵŶĚƐ ůŝŵŝƚĞĚŽƉĞŶŝŶŐ ůŽĐŬŝŶŐ ƉŽƉƉŝŶŐͿ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϮϮ ŽLJŽƵĨĞĞůůŝŬĞLJŽƵƌůŽǁĞƌũĂǁŝƐďĞŝŶŐƉƵƐŚĞĚďĂĐŬǁŚĞŶLJŽƵďŝƚĞLJŽƵƌƚĞĞƚŚƚŽŐĞƚŚĞƌ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϮϯ ŽLJŽƵĂǀŽŝĚŽƌŚĂǀĞĚŝĨĨŝĐƵůƚLJĐŚĞǁŝŶŐŐƵŵ ĐĂƌƌŽƚƐ ŶƵƚƐ ďĂŐĞůƐ ďĂŐƵĞƚƚĞƐ ƉƌŽƚĞŝŶďĂƌƐ ŽƌŽƚŚĞƌŚĂƌĚ ĚƌLJĨŽŽĚƐ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺϮϰ ,ĂǀĞLJŽƵƌƚĞĞƚŚĐŚĂŶŐĞĚŝŶƚŚĞůĂƐƚϱLJĞĂƌƐ ďĞĐŽŵĞƐŚŽƌƚĞƌƚŚŝŶŶĞƌŽƌǁŽƌŶ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϮϱ ƌĞLJŽƵƌƚĞĞƚŚĐƌŽǁĚŝŶŐŽƌĚĞǀĞůŽƉŝŶŐƐƉĂĐĞƐ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϮϲ ŽLJŽƵŚĂǀĞŵŽƌĞƚŚĂŶŽŶĞďŝƚĞĂŶĚƐƋƵĞĞnjĞƚŽŵĂŬĞLJŽƵƌƚĞĞƚŚĨŝƚƚŽŐĞƚŚĞƌ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϮϳ ŽLJŽƵĐŚĞǁŝĐĞ ďŝƚĞLJŽƵƌŶĂŝůƐ ƵƐĞLJŽƵƌƚĞĞƚŚƚŽŚŽůĚŽďũĞĐƚƐ ŽƌŚĂǀĞĂŶLJŽƚŚĞƌŽƌĂůŚĂďŝƚƐ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϮϴ ŽLJŽƵĐůĞŶĐŚLJŽƵƌƚĞĞƚŚŝŶƚŚĞĚĂLJƚŝŵĞŽƌŵĂŬĞƚŚĞŵƐŽƌĞ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϮϵ ŽLJŽƵŚĂǀĞĂŶLJƉƌŽďůĞŵƐǁŝƚŚƐůĞĞƉŽƌǁĂŬĞƵƉǁŝƚŚĂŶĂǁĂƌĞŶĞƐƐŽĨLJŽƵƌƚĞĞƚŚ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ϯϬ ŽLJŽƵǁĞĂƌŽƌŚĂǀĞLJŽƵĞǀĞƌǁŽƌŶĂďŝƚĞĂƉƉůŝĂŶĐĞ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
ϯϭ /ƐƚŚĞƌĞĂŶLJƚŚŝŶŐĂďŽƵƚƚŚĞĂƉƉĞĂƌĂŶĐĞŽĨLJŽƵƌƚĞĞƚŚƚŚĂƚLJŽƵǁŽƵůĚůŝŬĞƚŽĐŚĂŶŐĞ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϯϮ ,ĂǀĞLJŽƵĞǀĞƌǁŚŝƚĞŶĞĚ;ďůĞĂĐŚĞĚͿLJŽƵƌƚĞĞƚŚ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϯϯ ,ĂǀĞLJŽƵĨĞůƚƵŶĐŽŵĨŽƌƚĂďůĞŽƌƐĞůĨĐŽŶƐĐŝŽƵƐĂďŽƵƚƚŚĞĂƉƉĞĂƌĂŶĐĞŽĨLJŽƵƌƚĞĞƚŚ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϯϰ ,ĂǀĞLJŽƵďĞĞŶĚŝƐĂƉƉŽŝŶƚĞĚǁŝƚŚƚŚĞĂƉƉĞĂƌĂŶĐĞŽĨƉƌĞǀŝŽƵƐĚĞŶƚĂůǁŽƌŬ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
WĂƟĞŶƚ Ɛ^ŝŐŶĂƚƵƌĞ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺĂƚĞ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
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MEDICAL HISTORYWĂƟĞŶƚEĂŵĞ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ EŝĐŬŶĂŵĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ŐĞ ͺͺͺͺͺͺͺEĂŵĞŽĨWŚLJƐŝĐŝĂŶĂŶĚƚŚĞŝƌƐƉĞĐŝĂůƚLJ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺDŽƐƚƌĞĐĞŶƚƉŚLJƐŝĐĂůĞdžĂŵŝŶĂƟŽŶ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ WƵƌƉŽƐĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺtŚĂƚŝƐLJŽƵƌĞƐƟŵĂƚĞŽĨLJŽƵƌŐĞŶĞƌĂůŚĞĂůƚŚdžĐĞůůĞŶƚ'ŽŽĚ&ĂŝƌWŽŽƌ
DO YOU HAVE or HAVE YOU EVER HAD: YES NOϭ ŚŽƐƉŝƚĂůŝnjĂƚŝŽŶĨŽƌŝůůŶĞƐƐŽƌŝŶũƵƌLJ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϮ ĂŶĂůůĞƌŐŝĐƌĞĂĐƚŝŽŶƚŽ ĂƐƉŝƌŝŶ ŝďƵƉƌŽĨĞŶ ĂĐĞƚĂŵŝŶŽƉŚĞŶ ĐŽĚĞŝŶĞ ƉĞŶŝĐŝůůŝŶ ĞƌLJƚŚƌŽŵLJĐŝŶ ƚĞƚƌĂĐLJĐůŝŶĞ ƐƵůĨĂ ůŽĐĂůĂŶĞƐƚŚĞƚŝĐ ĨůƵŽƌŝĚĞ ŵĞƚĂůƐ;ŶŝĐŬĞů ŐŽůĚ ƐŝůǀĞƌ ͺͺͺͺͺͺͺͺͺͺ Ϳ ůĂƚĞdž ŽƚŚĞƌͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϯ ŚĞĂƌƚƉƌŽďůĞŵƐ ŽƌĐĂƌĚŝĂĐƐƚĞŶƚǁŝƚŚŝŶƚŚĞůĂƐƚƐŝdžŵŽŶƚŚƐͺͺϰ ŚŝƐƚŽƌLJŽĨŝŶĨĞĐƚŝǀĞĞŶĚŽĐĂƌĚŝƚŝƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϱ ĂƌƚŝĨŝĐŝĂůŚĞĂƌƚǀĂůǀĞ ƌĞƉĂŝƌĞĚŚĞĂƌƚĚĞĨĞĐƚ;W&KͿͺͺͺͺͺͺͺͺͺͺϲ ƉĂĐĞŵĂŬĞƌŽƌŝŵƉůĂŶƚĂďůĞĚĞĨŝďƌŝůůĂƚŽƌ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϳ ĂƌƚŝĨŝĐŝĂůƉƌŽƐƚŚĞƐŝƐ;ŚĞĂƌƚǀĂůǀĞŽƌũŽŝŶƚƐͿͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϴ ƌŚĞƵŵĂƚŝĐŽƌƐĐĂƌůĞƚĨĞǀĞƌ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϵ ŚŝŐŚŽƌůŽǁďůŽŽĚƉƌĞƐƐƵƌĞ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϭϬ ĂƐƚƌŽŬĞ;ƚĂŬŝŶŐďůŽŽĚƚŚŝŶŶĞƌƐͿ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϭϭ ĂŶĞŵŝĂŽƌŽƚŚĞƌďůŽŽĚĚŝƐŽƌĚĞƌ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϭϮ ƉƌŽůŽŶŐĞĚďůĞĞĚŝŶŐĚƵĞƚŽĂƐůŝŐŚƚĐƵƚ;/EZхϯϱͿ ͺͺͺͺͺͺͺͺͺϭϯ ĞŵƉŚLJƐĞŵĂ ƐŚŽƌƚŶĞƐƐŽĨďƌĞĂƚŚ ƐĂƌĐŽŝĚŽƐŝƐͺͺͺͺͺͺͺͺͺͺͺͺϭϰ ƚƵďĞƌĐƵůŽƐŝƐ ŵĞĂƐůĞƐ ĐŚŝĐŬĞŶƉŽdž ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϭϱ ĂƐƚŚŵĂ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϭϲ ďƌĞĂƚŚŝŶŐŽƌƐůĞĞƉƉƌŽďůĞŵƐ;ŝ Ğ ƐůĞĞƉĂƉŶĞĂ ƐŶŽƌŝŶŐ ƐŝŶƵƐͿϭϳ ŬŝĚŶĞLJĚŝƐĞĂƐĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϭϴ ůŝǀĞƌĚŝƐĞĂƐĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϭϵ ũĂƵŶĚŝĐĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϮϬ ƚŚLJƌŽŝĚ ƉĂƌĂƚŚLJƌŽŝĚĚŝƐĞĂƐĞ ŽƌĐĂůĐŝƵŵĚĞĨŝĐŝĞŶĐLJ ͺͺͺͺͺͺͺͺϮϭ ŚŽƌŵŽŶĞĚĞĨŝĐŝĞŶĐLJ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϮϮ ŚŝŐŚĐŚŽůĞƐƚĞƌŽůŽƌƚĂŬŝŶŐƐƚĂƚŝŶĚƌƵŐƐ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϮϯ ĚŝĂďĞƚĞƐ;,ďϭĐсͺͺͺͺͺͺ Ϳ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϮϰ ƐƚŽŵĂĐŚŽƌĚƵŽĚĞŶĂůƵůĐĞƌ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϮϱ ĚŝŐĞƐƚŝǀĞĚŝƐŽƌĚĞƌƐ;ŝ Ğ ĐĞůŝĂĐĚŝƐĞĂƐĞ ŐĂƐƚƌŝĐƌĞĨůƵdžͿͺͺͺͺͺͺͺ
Ϯϲ ŽƐƚĞŽƉŽƌŽƐŝƐ ŽƐƚĞŽƉĞŶŝĂ;ŝ Ğ ƚĂŬŝŶŐďŝƐƉŚŽƐƉŚŽŶĂƚĞƐͿ ͺͺϮϳ ĂƌƚŚƌŝƚŝƐ ƌŚĞƵŵĂƚŽŝĚĂƌƚŚƌŝƚŝƐ ůƵƉƵƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϮϴ ŐůĂƵĐŽŵĂ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϮϵ ĐŽŶƚĂĐƚůĞŶƐĞƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϯϬ ŚĞĂĚŽƌŶĞĐŬŝŶũƵƌŝĞƐ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϯϭ ĞƉŝůĞƉƐLJĐŽŶǀƵůƐŝŽŶƐ;ƐĞŝnjƵƌĞƐͿͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϯϮ ŶĞƵƌŽůŽŐŝĐĚŝƐŽƌĚĞƌƐ; ,ƉƌŝŽŶĚŝƐĞĂƐĞͿͺͺͺͺͺͺͺϯϯ ǀŝƌĂůŝŶĨĞĐƚŝŽŶƐĂŶĚĐŽůĚƐŽƌĞƐ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϯϰ ĂŶLJůƵŵƉƐŽƌƐǁĞůůŝŶŐŝŶƚŚĞŵŽƵƚŚ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϯϱ ŚŝǀĞƐ ƐŬŝŶƌĂƐŚ ŚĂLJĨĞǀĞƌ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϯϲ ^d/ d ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϯϳ ŚĞƉĂƚŝƚŝƐ;ƚLJƉĞ ͺ Ϳͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϯϴ ,/s / ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϯϵ ƚƵŵŽƌĂďŶŽƌŵĂůŐƌŽǁƚŚ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϰϬ ƌĂĚŝĂƚŝŽŶƚŚĞƌĂƉLJ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϰϭ ĐŚĞŵŽƚŚĞƌĂƉLJŝŵŵƵŶŽƐƵƉƉƌĞƐƐŝǀĞ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϰϮ ĞŵŽƚŝŽŶĂůƉƌŽďůĞŵƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϰϯ ƉƐLJĐŚŝĂƚƌŝĐƚƌĞĂƚŵĞŶƚ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϰϰ ĂŶƚŝĚĞƉƌĞƐƐĂŶƚŵĞĚŝĐĂƚŝŽŶͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϰϱ ĂůĐŽŚŽů ƐƚƌĞĞƚĚƌƵŐƵƐĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺARE YOU:ϰϲ ƉƌĞƐĞŶƚůLJďĞŝŶŐƚƌĞĂƚĞĚĨŽƌĂŶLJŽƚŚĞƌŝůůŶĞƐƐͺͺͺͺͺͺͺͺͺͺͺϰϳ ĂǁĂƌĞŽĨĂĐŚĂŶŐĞŝŶLJŽƵƌŚĞĂůƚŚŝŶƚŚĞůĂƐƚϮϰŚŽƵƌƐ ;ŝ Ğ ĨĞǀĞƌĐŚŝůůƐ ŶĞǁĐŽƵŐŚ ŽƌĚŝĂƌƌŚĞĂͿ ͺͺͺͺͺͺͺͺͺͺͺͺͺϰϴ ƚĂŬŝŶŐŵĞĚŝĐĂƚŝŽŶĨŽƌǁĞŝŐŚƚŵĂŶĂŐĞŵĞŶƚ;ŝ Ğ ĨĞŶͲƉŚĞŶͿϰϵ ƚĂŬŝŶŐĚŝĞƚĂƌLJƐƵƉƉůĞŵĞŶƚƐ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ϱϬ ŽĨƚĞŶĞdžŚĂƵƐƚĞĚŽƌĨĂƚŝŐƵĞĚ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϱϭ ĞdžƉĞƌŝĞŶĐŝŶŐĨƌĞƋƵĞŶƚŚĞĂĚĂĐŚĞƐ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϱϮ ĂƐŵŽŬĞƌƐŵŽŬĞĚƉƌĞǀŝŽƵƐůLJŽƌƵƐĞƐŵŽŬĞůĞƐƐƚŽďĂĐĐŽ ͺϱϯ ĐŽŶƐŝĚĞƌĞĚĂƚŽƵĐŚLJƉĞƌƐŽŶ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϱϰ ŽĨƚĞŶƵŶŚĂƉƉLJŽƌĚĞƉƌĞƐƐĞĚ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϱϱ &D>ͲƚĂŬŝŶŐďŝƌƚŚĐŽŶƚƌŽůƉŝůůƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϱϲ &D>ͲƉƌĞŐŶĂŶƚͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺϱϳ D>ͲƉƌŽƐƚĂƚĞĚŝƐŽƌĚĞƌƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
ĞƐĐƌŝďĞĂŶLJĐƵƌƌĞŶƚŵĞĚŝĐĂůƚƌĞĂƚŵĞŶƚŝŵƉĞŶĚŝŶŐƐƵƌŐĞƌLJ ŐĞŶĞƟĐĚĞǀĞůŽƉŵĞŶƚĚĞůĂLJ ŽƌŽƚŚĞƌƚƌĞĂƚŵĞŶƚƚŚĂƚŵĂLJƉŽƐƐŝďůLJĂīĞĐƚLJŽƵƌĚĞŶƚĂůƚƌĞĂƚŵĞŶƚ;ŝĞŽƚŽdžŽůůĂŐĞŶ/ŶũĞĐƟŽŶƐͿͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
>ŝƐƚĂůůŵĞĚŝĐĂƟŽŶƐƐƵƉƉůĞŵĞŶƚƐĂŶĚŽƌǀŝƚĂŵŝŶƐƚĂŬĞŶǁŝƚŚŝŶƚŚĞůĂƐƚƚǁŽLJĞĂƌƐ
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FINANCIAL POLICY
Excellent professional doctor/patient relations depend on mutual respect, trust and understanding. The fees we charge for services rendered are set according to the level of advanced dentistry. Our dental fee is unique because it is all inclusive—includes any commercial laboratory charges, use of trained auxiliary personnel, quality materials, treatment facilities, post-graduate training and the doctor’s time, skill, care and judgment. We always invite your questions. You will be provided with a complete description of a treatment plan and an estimate of the total fee. If you undertake the treatment plan, you will be responsible for payment of the fee regardless of your dental insurance benefits. If, during the course of treatment, we find additional treatment is needed, we will discuss the situation along with any additional costs prior to proceeding. The following payment options are as follows*:
• Full payment by cash, check or credit card on the day of service • Financing through one of our many financial institutions
For patients with dental insurance, payment is expected at the time of service by way of the above options. We now have the ability to send your claim electronically expediting the reimbursement process. As a courtesy to all our clients, insurance payments and out-of-pocket estimates are provided upon request. This is not a guarantee for payments, benefits or coverage. *Washington Dental Service/Delta Dental, Premera and Regence patients will be required to make any estimated co-payments at the time of the visit. We cannot offer any pre-payment savings for patients with these insurance participants. If you schedule an appointment for major restorative treatment, pre-payment is required, regardless of insurance coverage. Unpaid balances accrue finance fees of 1.50% after 30 days regardless of insurance benefits. Appointment cancellation/rescheduling less than 48 hours notice for hygiene visits will incur a $75 fee. Cancellations or rescheduling appointments on extended visits for major restorative treatment may forfeit partial prepayment fee or $250, (whatever amount is less) if less than 48 hours notice provided. Overpayments and credit balances will be refunded at the patient’s request after being processed and posted to the account. Credits may be applied to future dental treatment if desired. I have read and understand the financial policies stated above. Signed _______________________________________ Date ______________
Kim Okamura DDS 11730 15th Ave NE Seattle WA 98125 206.362.3200 fax 206.362.0621 www.KimOkamuraDDS.com [email protected]
STATEMENT'OF'PRIVACY'PRACTICES'Dr.$Kim$Okamura$
11730$15th$Ave$NE$Seattle$WA$98125$206.362.3200$
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!Protecting!your!personal!healthcare!information!We$use$and$disclose$the$information$we$collect$from$you$only$as$allowed$by$the$Health$Insurance$Portability$and$
Accountability$Act$and$the$State$of$Washington.$$This$includes$issues$relating$to$your$treatment,$payment$and$our$dental$care$operations.$$Your$personal$health$information$will$never$be$otherwise$given$to$anyone—even$family$members—without$your$written$consent.$$You,$of$course,$may$give$written$authorization$for$us$to$disclose$your$
information$to$anyone$you$choose,$for$any$purpose.$$Our$office$and$electronic$systems$are$secure$from$unauthorized$access$and$our$employees$are$trained$to$make$certain$that$the$confidentiality$of$your$record$is$always$protected.$$Our$privacy$policy$and$practices$apply$to$all$former,$current$and$future$patients;$you$can$be$confident$your$protected$
health$information$will$never$be$improperly$disclosed$or$released.$$Insurance$companies$will$not$receive$any$financial$information$other$than$their$reimbursement$information.$$
Collecting!protected!health!information!We$will$only$request$personal$information$needed$to$provide$our$standard$quality$of$dental$care,$implement$payment$
activities,$conduct$normal$dental$practice$operations$and$comply$with$the$law.$$This$may$include$your$name,$address,$telephone$numbers,$Social$Security$number,$employment$data,$medical$history,$health$records,$etc…$$While$most$of$the$information$will$be$collected$from$you,$we$may$obtain$information$from$third$parties,$if$it$deemed$necessary.$$
Regardless$of$source,$your$personal$information$will$always$be$protected$to$the$full$extent$of$the$law.$$Disclosure!of!your!protected!health!information!
As$stated$above,$we$may$disclose$information$as$required$by$law.$$We$are$obligated$to$provide$information$to$law$enforcement$and$governmental$officials$under$certain$circumstances.$$We$will$not$use$your$information$for$marketing$purposes$without$your$written$consent.$$We$may$use$and/or$disclose$your$health$information$to$communicate$
reminders$about$your$appointments$including$voicemail$messages,$text$messages,$email$and$postcards.$$Family$members,$and$in$some$cases,$others$will$have$access$to$your$PHI$in$the$event$of$your$death.$$
Patient!rights!You$have$the$right$to$request$copies$of$your$healthcare$information:$to$request$copies$in$a$variety$of$formats;$to$request$a$list$of$instances$in$which$we$or$our$business$associates$have$disclosed$your$protected$information$for$uses$
other$than$stated$above.$$All$requests$must$be$in$writing.$$We$may$charge$for$copies$in$an$amount$allowed$by$law.$$If$you$believe$your$rights$have$been$violated,$we$urge$you$to$notify$us$immediately.$$You$can$also$notify$the$US$Department$of$Health$and$Human$Services.$
$We$thank$you$for$being$a$patient$at$Kim$Okamura$DDS.$$Please$let$us$know$if$you$have$any$questions$concerning$your$privacy$rights$and$the$protection$of$your$personal$health$information.$
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