2022/2023 Practice Marketing & Office Supplies Catalog - 159

CLINICAL FORMS
A
CLINICAL FORM * MEDICAL HISTORY * HIPAA ACKNOWLEDGEMENT FORMS
D
A. ADA®
CLAIM FORM PAD 2019
* Revised in 2019 with editorial changes to
form, including captions and check-box
options for gender (M, F, and U), to be
consistent with the HIPAA standard
electronic dental claim (837D)
* This is the most recent version of the form
* 81
⁄2
" W x 11 " H
100-Sheet Pad
(368-3751)Ea
B
D. NOTICE OF PRIVACY PRACTICES
PATIENT ACKNOWLEDGEMENT
* Document patient's receipt of your
privacy policy
* 3-part form includes a copy for the patient,
their chart, and a copy for the Privacy Officer's file
* 2-hole punched at top
* 81
⁄2
" W x 11 " H, 5 lines
(367-3436)100 per Pkg
E
(368-3628)
B. ADA®
2021 HEALTH HISTORY FORMS
* Reflects the latest AHA premedication guidelines
* Clear, 2-sided layout and simple wording
* Includes questions related to intravenous
bisphosphonates and alendronates
Forms100 per Pad
Specify:
Adult-English
Adult-Spanish
Child-English
(368-3628)
(368-3629)
(368-3630)
C
THOROFARE PROFESSIONAL GROUP
500 GROVE ROAD
THOROFARE, NEW JERSEY 08086
(800) 555-1234
Notice of Privacy Practices
Patient Acknowledgement
Patient Name: _____________________________________________
Date of Birth: ___________________________
I have received and understand this practice's Notice of Privacy
Practices written in plain language. The notice provides in detail the
uses and disclosures of my protected health information that may be
made by this practice, my individual rights, how I may exercise these
rights, and the practice's legal duties with respect to my information.
I understand that this practice reserves the right to change the terms
of its Notice of Privacy Practices, and to make changes regarding all
protected health information resident at, or controlled by, this practice.
If changes to the policy occur, this practice will provide me a revised
Notice of Privacy Practices upon request.
C. NOTICE OF PRIVACY PRACTICES
PATIENT ACKNOWLEDGEMENT
SHORT FORM
* Padded form documents patient's receipt
of your privacy policy in succinct,
easy-to-understand terms
* 25 sheets per pad
Signature: ________________________________________________
Date:__________________________________
Relationship to patient (if signed by a personal representative of patient):
_________________________________________________________
G
E. NOTICE OF PRIVACY PRACTICES FORM
* Available in a handy padded format
* 100 sheets per pad
* If you purchase D, you must purchase B or C
* 81
⁄2
" W x 11 " H, 5 lines
(367-3437)5 Pads per Pkg
4 Pkg@
F
Back
Front
(Back not shown)
Front
F-G. HIPAA NOTICE OF PRIVACY
PRACTICES PRODUCTS
F Acknowledgement Labels
4 " x 2 "
Form # PRV2-3
(367-4180)100 per Pkg
5 Pkg@
3-Part-25 sheets per pad
(367-3435)5 Pads per Pkg
4 Pkg@
G Acknowledgement Labels
4 " x 1 "
(367-3088)100 per Pkg
5 Pkg@
For Imprinted Materials, contact: professional.promotions@henryschein.com
For pricing information and/or to place an order, visit: www.henryscheindental.com
159
2022/2023 Practice Marketing & Office Supplies Catalog

Table of Contents for the Digital Edition of 2022/2023 Practice Marketing & Office Supplies Catalog
