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Pana Orthodontic New Patient forms

Pana Orthodontics

26731 Aliso Creek Rd Ste 210,
Aliso Viejo, CA 92656
(949) 360-0225

Patient Details( * mandatory to fill )
PATIENT DETAILS( * mandatory to fill )

Insurance Information

COMPLETE THIS SECTION IF PATIENT IS A MINOR

  •  Same

OR

  •  Same

OR

I hereby authorize payment directly to Marc R. Pana, DDS for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents.

I authorize the use of this signature for your use and disclosure of health information to carry out treatment, payment activities, and health care operations.

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Orthodontic Health History( * mandatory to fill )
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  •  No

Has the patient had any of the illnesses listed below?

  •  Yes
  •  No
  •  Yes
  •  No
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  •  Review 6 Months
  •  Review 12 Months
  •  Review 18 Months
  •  Review 24 Months
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Respecting the Privacy of our Patients

 

We value the trust of our patients and are deeply committed to protecting the privacy of patient information. That is why we only collect and disclose information necessary to provide out patients with quality services. We welcome this opportunity to describe the steps we take to protect our patient’s information. Our goal is to ensure that you will fully understand our policies and practices regarding the collection, disclosure and protection of this information. You will receive a copy of our privacy statement at the beginning of our doctor-patient, or at your next visit for established patients. The privacy policies described in this statement apply to our current and former patients. It may be necessary to review and revise our privacy policies, in which case we will provide an updated privacy notice.

Information We Collect: In order to provide high quality services, we must collect and often share information about you and individuals covered under your insurance policy that is not publicly available. We do this to better service patients and process claims in a timely manner. We collect and may share the following types of information about you and your family covered by your policy: 1) Information about the identity of you and individuals covered under your policy, including the names, address, and social security numbers of such individuals. 2) Information we receive from you on applications or other insurance and account forms, such as the claims history or medical history of individuals covered under your policy. 3) Information about your transactions and experiences with us, such as the treatments you received from us, your payment history, account balance, and amounts you paid for your care.

Should we need to verify or obtain additional information about you or individuals covered under your policy, we may contact outside sources, such as agents, brokers, administrators, insurance support organizations, consumer reporting agencies, medical providers and government reporting agencies. Information collected from these outside sources may include information and claims or medical reports. Information obtained from outside sources may be retained by these outside sources and disclosed to other persons, in accordance with applicable laws.

How Such Information Is Used: In many cases, it is necessary to share some or all of the information listed above to help us deliver the best possible services to you and individuals covered under your policy. These disclosures are often necessary to fulfill transactions you have requested and to service the insurance policies that you have applied for and/or purchased. For example, we may share information with your insurance agent or broker, claims adjusters and administrators, claims investigators, and outside companies that perform administrative services on our behalf. We may share information about you and individuals covered under your policy to comply with legal and regulator requirements and for other limited purposes that are required or permitted by law. For example, we may share information about you and individuals covered under your policy to: 1) Process a transaction that you request. 2) Protect against fraud or criminal activity. 3) Report account activity to credit bureaus. 4) Comply with local, state or organizations, insurance support agencies, and law enforcement agencies.

Under no circumstances do we sell or share patient information to any outside party.

Access to and Correction of Individual Information: Individuals covered under your policy may write to us if they have any questions about the information that we may have in our records about them or the identity of those persons to whom their information was disclosed during the two years prior to their request. If they wish, they may review this information in person or receive a copy at a reasonable charge. Individuals covered under your policy can notify us in writing if they believe any information should be corrected, amended, or deleted, and we will review their request. We will either make the requested change or explain why we did not do so. If we do not make the requested change, they may submit a short written statement identifying the disputed information, which will be included in all future disclosures of their information.

Confidentiality and Security of Information: We dedicated significant resources to protect the security of our patient information. We restrict access to customer information to those individuals who need to know that information to provide services to you or individuals covered under your policy. We also maintain physical, electronic, and procedural safeguards to protect patient information, and to guard against its unauthorized use

(Please click below to draw/upload sign)
(Your IP Address : IP:54.211.135.32 )
( * mandatory to fill )

Respecting the Privacy of our Patients

We value the trust of our patients and are deeply committed to protecting the privacy of patient information. That is why we only collect and disclose information necessary to provide our patients with quality services. We welcome this opportunity to describe the steps we take to protect our patient’s information. Our goal is to ensure that you will fully understand our policies and practices regarding the collection, disclosure and protection of this information. You will receive a copy of our privacy statement at the beginning of our doctor-patient, or at your next visit for established patients. The privacy policies described in this statement apply to our current and former patients. It may be necessary to review and revise our privacy policies, in which case we will provide an updated privacy notice.

Information We Collect: In order to provide high quality services, we must collect and often share information about you and individuals covered under your insurance policy that is not publicly available. We do this to better service patients and process claims in a timely manner. We collect and may share the following types of information about you and your family covered by your policy: 1) Information about the identity of you and individuals covered under your policy, including the names, address, and social security numbers of such individuals. 2) Information we receive from you on applications or other insurance and account forms, such as the claims history or medical history of individuals covered under your policy. 3) Information about your transactions and experiences with us, such as the treatments you received from us, your payment history, account balance, and amounts you paid for your care.

Should we need to verify or obtain additional information about you or individuals covered under your policy, we may contact outside sources, such as agents, brokers, administrators, insurance support organizations, consumer reporting agencies, medical providers and government reporting agencies. Information collected from these outside sources may include information and claims or medical reports. Information obtained from outside sources may be retained by these outside sources and disclosed to other persons, in accordance with applicable laws.

How Such Information Is Used: In many cases, it is necessary to share some or all of the information listed above to help us deliver the best possible services to you and individuals covered under your policy. These disclosures are often necessary to fulfill transactions you have requested and to service the insurance policies that you have applied for and/or purchased. For example, we may share information with your insurance agent or broker, claims adjusters and administrators, claims investigators, and outside companies that perform administrative services on our behalf. We may share information about you and individuals covered under your policy to comply with legal and regulator requirements and for other limited purposes that are required or permitted by law. For example, we may share information about you and individuals covered under your policy to: 1) Process a transaction that you request. 2) Protect against fraud or criminal activity. 3) Report account activity to credit bureaus. 4) Comply with local, state or organizations, insurance support agencies, and law enforcement agencies.

Under no circumstances do we sell or share patient information to any outside party.

Access to and Correction of Individual Information: Individuals covered under your policy may write to us if they have any questions about the information that we may have in our records about them or the identity of those persons to whom their information was disclosed during the two years prior to their request. If they wish, they may review this information in person or receive a copy at a reasonable charge. Individuals covered under your policy can notify us in writing if they believe any information should be corrected, amended, or deleted, and we will review their request. We will either make the requested change or explain why we did not do so. If we do not make the requested change, they may submit a short written statement identifying the disputed information, which will be included in all future disclosures of their information.

Confidentiality and Security of Information: We dedicated significant resources to protect the security of our patient information. We restrict access to customer information to those individuals who need to know that information to provide services to you or individuals covered under your policy. We also maintain physical, electronic, and procedural safeguards to protect patient information, and to guard against its unauthorized use

(Please click below to draw/upload sign)
(Your IP Address : IP:54.211.135.32 )
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