Jeffrey A. Bona, DDS
Medical History Form

304 E. US Hwy 30
Schererville, IN 46375

P: (219) 322-7670

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

1. About You

2. Dental History

Please check if you have had problems with any of the following:

3. Medical History

Women are you...? (Check all that apply)

Are you allergic to any of the following? (Check all that apply)

4. Notice of Privacy Practices Acknowledgement

Notice of Privacy Practices

In the course of providing service to you, we create, receive, and store health information that identifies you. I understand that, under the Health Insurance Portability & Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

  • Conduct, Plan, and Direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly
  • Obtain payment from third-party payers (e.g. my insurance company)
  • Conduct normal healthcare operations such as quality assessments and physician certifications

The Notice of Privacy Practices you have been given describes these uses and disclosures in detail. You are free to refer to this notice at any time before you sign this form. As described in our Notice of Privacy Practices, the use and disclosure of your health information for treatment purposes not only includes care and service provided here but also disclosures of your health information as may be necessary or appropriate for you to receive follow-up care from another health professional. Similarly, the use and disclosure of your health information for purposes of payment includes:

  • Our submission of your health information to a billing agent or vendor for processing claims or obtaining payment
  • Our submission of claims to third-party payers or insurers for claims review, determination of benefits and payment
  • Our submission of your health information to auditors hired by third-party payers and insurers

Other aspects of payment described in our Notice of Privacy Practices. Our Notice of Privacy Practices will be updated whenever our privacy practices change. You can receive an updated copy of this notice from our office.

You have the right to ask us to restrict the uses or disclosures made for purposes of treatment, payment, or healthcare operations, but as described in our Notice of Privacy Practices, we are not obliged to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how to ask for a restriction.

5. Authorization and Consent

By signing this form I understand that the information I have given above is correct to the best of my knowledge, that it will be held in the strictest of confidence, and that it is my responsibility to inform the office of any changes to this information. I also authorize the dental staff to perform the necessary dental services I may need.

I also authorize the dental staff of Jeffrey A. Bona, DDS to disclose personal health information to the following person: