Patient Dental/Medical Health History And Treatment Consent Form Patient Information: Name: ___________________________________________________ Date of Birth: ______________________________ Address: ___________________________________________________________________________________________ City: ___________________ State: __________ Zip Code: _____________ Gender: □Female Phone #: _______________________________________ Race:

□White

□Black

□Hispanic

□Male

Alternate Phone #: ________________________________

□Asian/Pacific Islander

□Other, specify _____________________

Dental History What was the date of your last dental visit? _______________________________________________________________ Previous Dentist’s Name: ______________________________________________________________________________ Please list any concerns you have about dental treatments: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Medical History Are you currently under the care of a physician for any reason?

□Yes

□No

If yes, please state for what reason: ______________________________________________________________________ Physician’s Name: ____________________________________________________________________________________ When was your last physical? ___________________________________________________________________________ Please list any medications you are currently taking: __________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

Do you have any allergies?

□Yes

□No

If yes, specify: _______________________________________________________________________________ Are you pregnant?

□Yes

□No

Do you have or have you had any of the following: Acid Reflux Alcohol Addiction Asthma Auto Immune Disease Bleeding Disorder Biophosphonate Treatment Cancer or Tumors Diabetes Drug/Substance Abuse

Yes

No

□ □ □ □ □ □ □ □ □

□ □ □ □ □ □ □ □ □

HIV Positive/AIDS Joint Replacement Kidney Problems Learning Disability Liver Disease Low Blood Pressure Lung Disease Lupus Neurological Disorder

Yes

No

□ □ □ □ □ □ □ □ □

□ □ □ □ □ □ □ □ □

819 Bloomington Road • Champaign, IL 61820 (217) 356-1558 • www.promisehealth.org

Eating Disorder Epilepsy Fainting Spells Glaucoma Heart Disease / Surgery Heart Murmur Hepatitis A Hepatitis B Hepatitis C High Blood Pressure

Yes

No

□ □ □ □ □ □ □ □ □ □

□ □ □ □ □ □ □ □ □ □

Yes No Organ Transplant □ □ Pace Maker □ □ Psychiatric Care □ □ Radiation Therapy □ □ Rheumatic Fever □ □ STD □ □ Stroke □ □ Tuberculosis □ □ Thyroid Problems □ □ Other, specify ___________________________ _______________________________________

Have you been hospitalized in the last ten years? □Yes □No Has your physician told you to pre-medicate prior to dental appointments due to a medical condition? Do you use or have you used any of the following tobacco products? □Cigarettes □Cigars □Pipe □Chewing Tobacco

□Yes

□No

Sliding Fee Scale Discount Policy Promise Healthcare maintains a standard procedure for qualifying patients for sliding fee scale discounts for services provided. Sliding fee scale discounts are available to patients with income less than 200% of the federal poverty guidelines. Sliding fee scale discounts apply to all directly provided Promise Healthcare services, and for select ancillary services, as feasible, based on availability of resources and/or agreement by non-Promise Healthcare providers providing services to Promise Healthcare patients. Authorization to receive treatment I, ____________________________________________________ hereby authorize SmileHealthy staff to provide recommended dental services including but not limited to exam, cleaning, fluoride treatment, sealants, X-rays or restorative care that may include fillings or extractions and possibly to administer local anesthetics. I fully understand and am fully informed that there are inherent risks involved in the administration of any drug, medicament, antibiotic, or local anesthetic. I fully understand that there are inherent risk involved in any dental treatment and extractions. The most common risks can include, but are not limited to: Bleeding, swelling, bruising, discomfort, stiff jaws, infection, aspiration, paresthesia, nerve disturbance or damage, adverse drug response, allergic reaction, and cardiac arrest. I realize that it is mandatory that I follow any instruction given by the dentist and his/her associates and take any medications as directed. Alternative treatment options, including no treatment, have been discussed with me. No guarantees have been made to me as to the results of treatment. A full explanation of all complications is available upon request. I acknowledge receipt of Patients Rights, Privacy Notice and Sliding Fee Scale Discount Policy.

___________________________________________________ Patient Name

_________________________________ Date

___________________________________________________ Patient/Guardian Signature

__________________________________ Relationship to Patient

Promise Healthcare Application for Sliding Fee Scale Discount If you need assistance completing any part of this application, please talk with a Promise Healthcare staff member. Only one form is necessary per household

Applicant Name: _____________________

Birthdate: ________

Address: ___________________________________ Phone Number: _________________________

Social Security Number: _________

City: __________

State: ____

Zip: ________

Alternate Phone Number: ______________________  Yes  No

Do you or does someone in your family have medical insurance? Do you or does someone in your family have dental insurance?

 Yes  No

If yes, please complete below. Add additional sheets as necessary. Medical Insurance Company Name: ________________________________________________________ Policy #: __________________

Group #: __________________

Company Address: ___________________________

Subscriber #: __________________

City: __________

State: ____

Zip: ________

Dental Insurance Company Name: _________________________________________________________ Policy #: __________________

Group #: __________________

Company Address: ___________________________

Are you a U.S. veteran?

Subscriber #: __________________

City: __________

State: ____

Zip: ________

 Yes  No

Within the last 24 months, have you worked or are you the dependent of someone who has worked in agriculture, either on a farm or in an agricultural-based industry?  Yes  No If yes, which applies?  Migrant

 Year-Round Employment

 Seasonal Permanent Resident

(establishes temporary residence in area)

(permanent residence in area)

(permanent resident in area)

Type of Housing (check one)  Rent or own home

 Homeless Shelter

 Doubled Up (live with another person or family unit)

 Transitional (live place to place)

 Street

 Other

List all dependents (if more than 6 dependents, please list on separate page) Name and Social Security Number

Date of Birth

Page 1 of 2

Relationship to Applicant

Do They Have: Medicaid Other Insurance

Income Summary Table Sources

Total Household Income

Wages Interest/Dividend Income Self-Employment, Rental Income Public Assistance, Social Security/Disability, Food Stamps/SNAP Unemployment Compensation Workers Compensation Child Support, Alimony Retirement Pension Assistance from Family/Friends

Accepted Documentation Last federal income tax return or last two paycheck stubs prior to the signature date on this application. Bank, credit union, savings statement or 1099. Ledger of income and expenses for the current year. Award letter(s) listing amount received in the current year. If you receive more than one, please add them together. Unemployment compensation benefit award letter for the current year. Worker’s compensation benefit award letter for the current year. Divorce decree stating child support or alimony received. Letter supplied by system administrator with monthly benefit amount for the current year. A notarized statement from family or friends explaining any financial help that they give you.

Other (Specify) Total Number of people supported by household income: ____________________ If you have any additional documents that may help Promise Healthcare make a determination regarding your application, please include them with this application. Patients who qualify for certain levels of sliding fee discounts are expected to also apply for other programs if requested to do so including Medicaid, other public and/or private health insurance and/or discount programs available for which you may qualify, including prescription drug assistance from pharmaceutical companies. Although a patient’s inability to pay for services will not prohibit services being provided, a patient who refuses to pay even though able to pay will be subject to collection activities. Patients are expected to be in compliance with Health Resources and Services Administration/Bureaus of Primary Health Care policies and regulations in order to receive medical services.

I understand that all of the information given may be confirmed by Promise Healthcare. I also understand that providing false information is considered fraud and will result in a denial of the Sliding Fee Scale Program application and that I will owe the charges for the services provided. I understand that if I am approved, the discount is good for one year from the date of the application and that I will need to complete another application at that point in order for the discount to continue. I also understand that if I am approved for the discount, I am obligated to inform Promise Healthcare if my financial situations improve, so that Promise Healthcare can re-evaluate my eligibility for the discount.

Applicant Signature (required): __________________________________________

Date: __________

Promise Healthcare Internal Use Only: Total Income: _______________

Number in Household: _______________

Staff Signature: _______________________________________________________

Date: __________

Page 2 of 2

Income Form 1 Approved by Promise Healthcare Board of Directors 8-27-13

SmileHealthy Dental Center Cancellation Policy MAKE AN APPOINTMENT, KEEP AN APPOINTMENT TO GIVE OUR PATIENTS THE BEST CARE POSSIBLE, WE NEED YOU TO ATTEND AND BE ON TIME FOR YOUR APPOINTMENT If you cannot attend your appointment:  You must give a 24 hour notice of cancellation.  If less than 24 hours notice, it will be marked as a missed appointment If you do not cancel and do not come to the appointment, you will be marked as a no-show appointment. You will be discharged from the program if you have three (3) no-show/missed appointments in a one (1) year period. To participate in the program after you have been discharged, you must:   

Submit a written request to the dentist for re-admission to the program. The letter must explain the reasons why you did not keep your missed appointments. Re-admission is at the discretion of our dentist.

PLEASE MARK YOUR CALENDAR KNOW THE TIME

I have read this policy and understand my responsibility.

____________________________ Signature

____________________________ Printed Name

819 Bloomington Road • Champaign, IL 61820 (217) 356-1558 • www.promisehealth.org

Patients’ Rights As an individual receiving services through Promise Healthcare, you have the right: To receive services regardless of your age, race, color, sexual orientation, religion, marital status, gender, national origin or sponsors. To be treated with consideration, respect and dignity, including privacy treatment. To be informed of services available at our health center. To be informed of provisions for off-hour emergency coverage. To be informed of the charges for services, eligibility for third-party reimbursements and, when applicable, the availability of free or reduced cost care. To receive an itemized copy of your account statement upon request. To obtain from our health center, complete and current information concerning your diagnosis, treatment and prognosis in terms you can be reasonably expected to understand. To refuse to participate in experimental research. To receive from your clinician, information necessary to give informed consents prior to the start of any nonemergency procedure and/or treatment. An informed consent shall include, as a minimum, the provision of information concerning the specific procedure and/or treatment, the reasonable foreseeable risks involved, and alternatives for care or treatment, if any, as a reasonable medical practitioner under similar circumstances would disclose in a manner permitting you to make a knowledgeable decision. To refuse treatment to the extent permitted by law and to be fully informed of the medical consequences of this action. To voice grievances and recommend changes in policies and services to the agency staff, the administrator of the agency, or the Department of Health without fear of reprisal. To express complaints about the care and services and to have the health center investigate such complaints. Promise Healthcare is responsible for providing you or your designee with a written response within 30 days, if requested, indicating the findings of the investigation. The agency is also responsible for notifying you or your designee that if you are not satisfied by the agency response, you may complain to the Illinois State Department of Health’s Office of Health Systems Management. To have the privacy and confidentiality of all information and records pertaining to your treatment at Promise Healthcare facilities. To approve or refuse the disclosure information of the contents of your medical record to any health care practitioner and/or health care facility except as required by law or thirdparty payment contract. To access your medical record.

819 Bloomington Road • Champaign, IL 61820 (217) 356-1558 • www.promisehealth.org

Promise Healthcare HIPAA Notice of Privacy Practices This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. How to Contact Us/Our Privacy Official If you have any questions or would like further information about this Notice, you can either write to or call the Privacy Official for Promise Healthcare: Jill Myers 819 Bloomington Rd. Champaign, IL 61820 217-403-5404 Our Use and Disclosure of Your Health Information Without Your Written Authorization Treatment. We may disclose health information about you to dental specialists, physicians, or other health care professionals involved in your care. Payment. We may use and disclose your health information to obtain payment from health plans and insurers for the care that we provide to you. Health Care Operations. We may use and disclose health information about you in connection with health care operations necessary to run our practice, including review of our treatment and services, training, evaluating the performance of our staff and health care professionals, quality assurance, financial or billing audits, legal matters, and business planning and development. Appointment Reminders. We may use or disclose your health information when contacting you to remind you of your appointment. We may contact you by using a postcard, letter, voicemail, or email. Disclosure to Family Members and Friends. We may disclose your health information 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. Disclosures Required by Law. We are required to disclose patient health information to the U.S. Department of Health and Human Services so that it can investigate complaints or determine our compliance with HIPAA. Public Health Activities. We may disclose patient health information for public health activities and purposes, which include: preventing or controlling disease, injury or disability; reporting births or deaths; reporting child abuse or neglect; reporting adverse reactions to medications or foods; reporting product defects; enabling product recalls; and notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. Victims of Abuse, Neglect, or Domestic Violence. We may disclose health information to the appropriate government authority about a patient whom we believe is a victim of abuse, neglect or domestic violence. Health Oversight Activities. We may disclose patient health information to a health oversight agency for activities necessary for the government to provide oversight of the health care system, government benefit programs, and compliance with certain civil rights laws. Lawsuits and Legal Actions. We may disclose patient health information in response to (i) a court or administrative order or (ii) a subpoena, discovery request, or other lawful process if efforts have been made to notify the patient. Law Enforcement Purposes. We may disclose patient health information to a law enforcement official for law enforcement purposes. Coroners, Medical Examiners and Funeral Directors. We may disclose patient health information to a coroner, medical examiner or funeral director to allow them to carry out their duties. Tissue Donation. We may use or disclose patient health information to organ/tissue procurement organizations or others that obtain, bank, or transplant tissue for donation. Serious Threat to Health or Safety. We may use or disclose patient health information if we believe it is necessary to do so to prevent or lessen a serious threat to anyone’s health or safety. Specialized Government Functions. We may disclose patient health information to the military (domestic or foreign) about its members or veterans, for national security and protective 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. Workers’ Compensation. We may disclose patient health information to comply with workers’ compensation laws or similar programs that provide benefits for work-related injuries or illness. We will make other uses and disclosures of health information not discussed in this Notice only with your written authorization. You may revoke that authorization at any time in writing. Your Rights with Respect to Your Health Information Access. You may request to review or request a copy of your health information. We may deny your request under certain circumstances. You will receive written notice of a denial and can appeal it. Amend. If you believe that your health information is incorrect or incomplete, you may request that we amend it. We may deny your request under certain circumstances. Restrict Use and Disclosure. 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. Receive a Paper Copy of This Notice. You have the right to a paper copy of this Notice. We reserve the right to change the terms of this Notice at any time. To Make Privacy Complaints If you have any complaints about your privacy rights or how your health information has been used or disclosed, you may file a complaint with us by contacting our Privacy Official listed on the first page of this Notice. You may also file a written complaint with the U.S. Department of Health and Human Services Office for Civil Rights. The privacy of your health information is important to us. We will not retaliate against you in any way if you chose to file a complaint.