Patient Information
Marital Status:
Person Responsible For Account
Dental Insurance Information

Payment is due in full at time of treatment unless prior arrangements have been approved.
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.
So that we can maintain the operation of our office on sound principles and to assure you and other patients of uninterrupted treatment, it is necessary for all patients to accept and adhere to a definite arrangement of appointments. Once you have made an appointment, remember this time is reserved for you. THEREFORE APPOINTMENTS THAT ARE CANCELLED WILL NOT BE CHARGED IF 24-HOURS NOTICE IS GIVEN.
I hereby authorize, Ronald J. Levine, DMD, to furnish the insured’s insurance company all information and that said insurance company may request concerning my present illness. I hereby assign to Ronald J. Levine, DMD all money to which I am entitled for dental expense relative to the services performed, but not to exceed my indebtedness. I understand I am financially responsible to Ronald J. Levine, DMD for charges not covered by this assignment.

Medical History
Are you being treated by a doctor now?:
Taking any medicine, including over the counter?:
Are you sensitive or allergic to any medications?:
Ever been hospitalized or had any surgical procedures?:
Do you need to be pre-medicated for dental treatment?:
Do you have a history of drug or alcohol addiction?:
Do you use tobacco products?:
Female Patients
Are you taking oral contraceptives?:
Are you taking Hormone Replacement Therapy?:
Are you pregnant or lactating?:
Do you have or have you had:
Artificial Joints:
Bleeding Disorder:
Head Injuries:
Heart Attack:
Heart Murmur:
High Blood Pressure:
Kidney Disease:
Liver Disease:
Mental Disorder:
Mitral Valve Prolapse:
Nervous Disorders:
Radiation Therapy:
Respiratory Problem:
Rheumatic Fever:
Sinus Problems:
Thyroid Disease:
Venereal Disease:
Are you excessively nervous or depressed?:
Have you ever been treated for nervous or mental disorders?
Do you find it necessary to sleep with two pillows at night?
Have you recently gained or lost excessive amounts of weight?
Have you had abnormal bleeding after a cut or tooth extraction?
Ever had an injury to your face or jaw?:
Have you noticed any loosening of your teeth?:
Do you suffer from pain and/or swelling of your gums?
Do your gums often bleed when you brush your teeth?
Do you have an unpleasant odor or taste in your mouth?
What else do you use to clean your teeth?:
Do you feel apprehensive when you have dental treatment?
Would you like to use Nitrous Oxide (Laughing gas) in conjunction with treatment?
Does the fear of pain make you postpone dental treatment?
Is it important for you to keep your teeth?
Notice of Privacy Practices



We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices that are described in this Notice while it is in effect. This Notice takes effect 4/13/03, and will remain in effect until we replace it.

We reserve the right to change our privacy practice and applicable law permits the terms of this Notice at any time, provided such changes. We reserve the right to make the changes in our privacy practices and the new terms of our Notice will remain effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include the quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization. We cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons involved in care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so, by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety to others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized, federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement officials having lawful custody of protected health information of an inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

Access: You have the right to look at or request copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of the Notice. We will charge a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $.25 per page, $8.00 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary of an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure).

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use and disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing). Your request must specify the alternative means or location and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended). We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of the Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. 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.

Contact Officer: Dr. Ronald Levine
Telephone: (530) 363-6852
Address: 1045 Willagillespie Road, Suite 125
Eugene, OR 97401

**You May Refuse to Sign This Acknowledgement**

I have received a copy of this office's Notice of Privacy Practices.


We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

  1. Individual refused to sign.
  2. Communications barriers prohibited obtaining the acknowledgement.
  3. An emergency situation prevented us from obtaining acknowledgement.
  4. Other (Please Specify).