Orthodontic Child Patient Forms | Orthodontics Los Angeles & Santa Monica

Personal Information
Patient Full Name*
Patient First Name Patient Middle Name Patient Last Name
Grade
Date of Birth*
Name of School
Gender
- Male
- Female
Home Address
Street Address Address Line 2 City State ZIP Code
Parent's Names*
Mother's Name Father's Name
Mother's Employer
Father's Employer
Mother's Occupation
Social Security Number
Father's Occupation
Social Security Number
Siblings
Patient Lives With
- Mother
- Father
- Both Parents
Billing Name
Relationship with Patient
Billing Address
Street Address Address Line 2 City State ZIP Code
Who may we thank for referring you?

Insurance Information
Parent/Guardian Initials
Date
Insured's Name
Insured's SSN or IDN
Insured's Employer
Insurance Company
Insurance Phone Number
Insurance Address
Street Address Address Line 2 City State ZIP Code
Group Number
Local Number
Do you have orthodontic coverage?
- Yes
- No
If yes, benefit amount:
If you have secondary insurance
Insured's Full Name
Insured's First Name Insured's Middle Name Insured's Last Name
Insured's Employer
Social Security Number
Insurance Company
Insurance Phone Number
Insurance Address
Street Address Address Line 2 City State ZIP Code
Group Number
Local Number
Do you have orthodontic coverage?
- Yes
- No
If yes, benefit amount:

Emergency Information
Name of nearest relative not living with you
Relative's First Name Relative's Middle Name Relative's Last Name
Relative's Phone Number
Relative's Address
Street Address Address Line 2 City State ZIP Code

Notice of Privacy Practices*
How Los Angeles Orthodontist Dr. Nikaeen Protects Your Rights and Data
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE READ AND REVIEW IT CAREFULLY.
The privacy of your health information is very important to us. Pursuant to federal and state laws, we have developed a guideline to protect your privacy. The current privacy practices that are outlined went into effect on April 14, 2003 and will remain in effect until further notice. We reserve the right to change these privacy practices at any time as permitted by applicable law. However, before any significant change, we will change this notice to our patients.
You may request a copy of our notice at any time. For additional information about our privacy practices, or for additional copies of this notice, please contact us using the information provided on the reverse side.
USES AND DISCLOSURE OF HEALTH INFORMATION
Treatment: We may use your health information for treatment or disclose it to another dentist, specialist, physician or other health care provider providing treatment to you.
Payment: We may use and disclose your health information to third parties to obtain payment for services that we provide for you.
Health Care Operations: We may disclose your health information for our health care operations. This includes quality assessment and improvement activities as well as reviewing the competence or qualifications of our staff and or healthcare professionals.
Appointment Reminders: We may use your information to provide you with appointment reminders. We could use postcards, letters, phone/voicemail or e-mail.
Public Benefits: In some rare instances we might be required by law to disclose your health information. These occasions could include:
To assist federal, state or local government agencies and private disaster assistance organizations engaged in disaster relief activities.
Public health activities such as vital statistics reporting in cases of communicable diseases, child abuse or neglect, or any matter subject to FDA oversight.
Disclosure about victims of abuse, neglect, or domestic violence.
Uses and disclosures for health oversight activities.
Disclosures and uses for judicial and administrative proceedings.
Disclosure for law enforcement activities.
Uses and disclosures about descendants.
Uses and discloses for cadaveric donation.
Disclosures to avert a serious threat to public health and safety.
Disclosures for specialized government functions; this could include disclosure to military command when treating members of the armed forces, where the authority is established by notice in the Federal Register.
Disclosures for Worker’s Compensation.
Any other disclosure specifically required by law.
PATIENT RIGHTS
Access: You have the right to review and receive a copy of your health information with very limited exceptions. If for any reason your request is denied, you have the right to have the denial reviewed. You will need to make a request in writing to gain access to your records. You have the right to receive the requested information within 30 days if they are maintained on-site. We may charge a reasonable, cost-based fee for copying or duplicating records.
Amendment: You have the right to have us amend your protected information. We may deny the request if we did not create the protected information, or if we determine that the information in dispute is accurate and complete.
Accounting of Disclosures: You have the right to receive an accounting if disclosures made by us or our business associates, within the past six years (but after the enactment of the current law), for the purposes other than treatment, payment, or health care operations. You may have the right to receive one free accounting per 12 month period. For additional requests, we may charge a reasonable, cost-based fee. You can obtain information about fees by contacting us prior to the request.
Restrictions: You have the right to request that uses and disclosures of your protected health information to carry out treatment, payment, or healthcare operation be restricted. We have the right to not agree. However, if we do agree, we will adhere to restrictions. Exceptions occur under emergency treatment situations.
Confidential Communications: You have the right to request that we provide confidential communications of protected information about you. You may request that we send communications by alternative means or at alternative locations. We will accommodate all reasonable requests; reasonableness is determined solely on the basis of administrative difficulty of complying with the request. Unless you indicate that the disclosure could endanger you. Request may be refused if you have not provided information as to how payment will be handled or if you have not specified an alternative address or method of contact.
QUESTIONS AND COMPLAINTS
If you have any further questions or to make a specific request about how we handle your protected information, please feel free to contact our privacy contact as noted at the bottom of this page. If you believe that we have mishandled your information or your requests on how to handle it, you have the right to submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with their address upon request. Your privacy is very important to us and we will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
Privacy Contact:
Atoosa Nikaeen Orthodontics
11600 Wilshire Boulevard, Suite 226
Los Angeles, CA 90025
PH (310) 444.1113
FAX (310) 444.1123
- I acknowledge that I have read the Notice of the Privacy Practices of Atoosa Nikaeen Orthodontics

Child Patient Form LA

Step 1 of 6 - Personal Information

Personal Information

Medical History

Dental History

Insurance Information

Emergency Information