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TO THE PATIENT, PARENT, OR GUARDIAN — PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.
Purpose of Consent: By signing this form, youwill consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.
Notice of Privacy Practices: You have the right to read our Joint Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other importantmatters about your protected health information.
A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent. You are entitled to a copy of this formif you would like one... just ask.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Joint Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
You may obtain a copy of ourJoint Notice of Privacy Practices, including any revisions of ourNotice, at any time by contacting:
Kool Smiles P.C.
HIPAA ComplianceOffice
1090NorthchaseParkwaySE
Suite 150 & 290
Marietta,GA30067
(770)916-9000
Right to Revoke: Youwill have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance of this Consent before we received your revocation, and that wemay decline to treat you or to continue treating you if you revoke this Consent.
SIGNATURE
I, _________________________________________, have had full opportunity to read and consider the contents of this Consent form and KoolSmiles, P.C.Joint Notice of Privacy Practices. I understand that by signing thisConsent form, I am giving my consent to KoolSmiles, P.C. use and disclosure of the patient’s protected health information to carry out treatment, payment activities, healthcare operations and other uses described in theKoolSmiles P.C.Joint Notice of Privacy Practices thatwas provided to me.
Signature:
Date:
Relationship to Patient:
翻译文本 - Swahili斯瓦西里语 IDHINI YA KUTUMIA NA KUFICHUA TAARIFA YA AFYA
Jina:
Jina La Mgonjwa:
Anwani:
Nambari ya Simu:
Nambari Ya Siri:
KWA MGONJWA, MZAZI, AU MCHUNGAJI – TAFADHALI SOMA MATAMKO YAFUATAYO KWA MAKINI
Madhumuni ya Idhini: Kwa kutia saini fomu hii, unakubali matumizi yetu na kutoa taarifa zako za afya kwa kutekeleza matibabu, shughuli za malipo, na shughuli za huduma ya afya.
Taarifa ya Utibabi wa Faragha: Una haki ya kusoma Ilani yetu ya Pamoja ya Utibabi wa Faragha kabla ya kuamua kitai sahihi Idhini hii. Ilani yetu hutoa maelezo ya matibabu yetu, shughuli za malipo, na shughuli za huduma ya afya, ya matumizi na utoaji wa taarifa zako za afya tunaweza kufanya, na mambo mengine muhimu kuhusu taarifa zako za afya.
Nakala ya Ilani yetu hii inaambatana na Idhini hii. Tunakuomba uisome kwa makini na kabisa kabla ya kutia saini yako kwenye Idhini hii. Una haki ya kuwa na nakala ya fomu hii kama ungependa moja... uliza tu.
Tuna haki ya kubadilisha utibabi wa faragha zetu kama ilivyoelezwa katika Ilani yetu ya Utibabi wa Faragha. Kama tutabadilisha utibabi wa faragha zetu, tutatoa upya Ilani ya utibabi wa faragha, ambayo itakuwa na mabadiliko. Mabadiliko hayo yanaweza kutumika kwa taarifa yako yeyote ya afya ambayo tutakuwa nayo.
Unaweza kupata nakala ya Ilani yetu ya utibabi wa Faragha, ikiwa ni pamoja na marekebisho ya Ilani yetu, wakati wowote kwa kuwasiliana na:
HIPAA Compliance Office
1090NorthchaseParkwaySE
Suite 150 & 290
Marietta,GA30067
(770)916-9000
Haki ya Kupinga: Uko na haki ya kupinga hii Idhini wakati wowote kwa kutuma taarifa ya maandishi ya ubatilishaji wako kwa alietajwa hapo juu. Tafadhali elewa kwamba kuondolewa kwa Idhini hii hakutaathiri kitendo chochote tulichokifanya katika utegemeziwa Idhini hii kabla ya sisi kupokea barua ya kuondolewa kwako, na kwamba tunaweza kataa kukutibu wewe au kuendelea kukutibu wewe kama utaipinga hii Idhini.
SAHIHI
Mimi, _________________________________________, nimepata na nafasi kamili yakusoma na kuzingatia yaliyomo kwenye Idhini hii na KoolSmiles PC, Ilani ya Pamoja ya utibabi wa Faragha.
Ninaelewa kwamba kwa kutia sahihi kwenye fomu hii ya Idhini, mimi ninawapatia ruhusa yangu KoolSmiles, PC watumie na wafichue taararifa ya mgonjwa kwa shughuli za matibabu, shighuli
za malipo, shughuli za afya na matumizi mengine ilivyoelezwa katika Ilani ya KoolSmiles PCJoint ya utibabi wa Faragha niliyopatiwa mimi.
Sahihi:
Tarehe:
Uhusiani na Mgonjwa:
English英语译成Swahili斯瓦西里语: New Patient's Information Form for Wrld Health Organization General field: 医学 Detailed field: 营销/市场调研
原文文本 - English英语 NPI-E Rev.04-2009
New Patient Health Information
Patient's Full Name:
Age:
Date of Birth:
Prefers to be called:
Sex:
Weight:
NO YES
Please Explain
Does patient have any health problems?
Is patient under the care of a physician now?
Has patient ever been hospitalized?
Does patient bleed excessively when cut or bruise easily?
Has patient had emotional or mental problems?
Has patient ever had any drug reactions?
Has patient ever had a local anesthetic?
Has patient had any unfavorable dental experiences?
Have patient had any injuries to the mouth or teeth?
Does patient have a toothache today or in the past month?
Is patient allergic to any medications?
Is patient allergic to any foods or drink (i.e. milk, bananas)?
Does patient have environmental allergies?
Is patient allergic to any materials commonly used in a dental office (i.e. latex gloves, anesthetic, etc.)? Explain.
Does patient have any of the following habits? (Thumb/finger sucking, tongue thrust, mouth breathing, snoring,
belching/burping) (Please circle.)
Please list prescription medication(s) being taken by the patient:
Name and phone # of patient’s pediatrician or physician:
Name and phone # of patient’s specialty medical care provider:
Has patient ever had any history or difficulty with the following? If so, please mark an "X" in the spaces provided.
( ) Cancer ( ) HIV ( ) Anemia ( ) Mononucleosis ( ) Cystic Fibrosis
( ) Liver ( ) Asthma ( ) Hepatitis ( ) Cerebral Palsy
( ) Lung ( ) Fainting ( ) Seizures ( ) Spinal Bifida ( ) Nervous Disorder
( ) Kidney ( ) Diabetes ( ) Convulsions ( ) Speech Problems ( ) Skin Condition
( ) Bladder ( ) Mumps ( ) Tuberculosis ( ) Pregnancy ( ) Developmental Delay
( ) Hearing ( ) Measles ( ) Malignancy ( ) Cleft Lip or Palate ( ) Hydrocephaly/Shunts
( ) Smoking ( ) Rubella ( ) Hemophilia ( ) Rheumatic Fever ( ) High Blood Pressure
( ) TMJ ( ) Autism ( ) Heart Surgery ( ) Thyroid ( ) Heart Disease/Congenital Defect
Please explain:
Reason for today's visit:
Please identify any dental or medical problems of special concern, or provide any other information which you think might be important in the patient’s care:
CERTIFICATION AND CONSENT FOR TREATMENT
I certify that I am the patient or parent/legal guardian of the patient listed above and the information provided in this form
is true and correct to the best of my knowledge. I also give my consent for my child or myself to receive a complete oral and dental examination (including any necessary x-rays) and dental cleaning. After consultation, I consent to all forms of treatment, medication, and therapy indicated for the dental care of the above named patient. I also understand that I am personally responsible for any patient portions left on my account. This agreement is made with Kool Smiles PC.
Signature: _____________________ Relationship to Patient (if patient is minor): ___________ Date: ________
Dentist Signature: Date:
翻译文本 - Swahili斯瓦西里语 Habari za Afya za Mgonjwa Mpya
Juna Kamili La Mgonjwa:
Umri:
Siku ya Kuzaliwa:
Anapendelea Kuitwa: Jinsia:
Uzani:
NDIO LA
Tafadhali Eleza
Je, mgonjwa ako na matatizo yoyote ya afya ?
Je, mgonjwa ako chini ya uangalizi/matibabu wa daktari kwa sasa?
Je, mgonjwa amewahi kulazwa hospitalini?
Je, mgonjwa hutokwa na damu kupita kiasi wakati anapo katwa au mchubuko?
Je, mgonjwa amewahi kuwa na matatizo ya kihisia au kiakili?
Je, mgonjwa amewahi kuwa na athari yoyote ya madawa?
Je, mgonjwa amewahi kuwa na dawa ya kugandisha misuli ya kienyeji?
Je, mgonjwa amewahi kuwa na uzoefu mbaya wowote wa meno?
Mgonjwa amewahi kuwa na majeraha yoyote kwa kinywa au meno?
Je, mgonjwa ako na maumivu ya meno leo au katika mwezi uliopita?
Je, mgonjwa ako na mzio wa dawa yoyote?
Je, mgonjwa ako na mzio wa vyakula au vinywaji (yaani maziwa, ndizi)?
Je, mgonjwa ako na mzio wa mazingira?
Je, mgonjwa ako na mzio wa nyenzo yoyote ya kawaida inayotumika katika cliniki ta meno (yaani glavu za mpira, dawa ya kugandisha misuli, na kadhalika)? Eleza.
Je, mgonjwa ako na moja ya tabia zifuatazo au mazoea yafuatayo? (Kunyonya kidole, kutia ulimi, kupumua na mdomo, mkoromo, mbweu/viungulia) (Tafadhali piga duara)
Tafadhali arodhesha dawa au madawa anazotumia mgonjwa:
Jina na nambari za simu za daktari wa mgonjwa:
Jina na nambari za simu za mtoa huduma maalum za afya wa mgonjwa:
Je, mgonjwa amewahi kuwa na historia yoyote au matatizo yafuatayo? Kama ni hivyo, tafadhali eka alama ya "X" katika nafasi iliyotolewa.
( )Saratani ( )Ukimwi ( )Safura ( )Mononucleosis
( ) Uvimbe adilifu ( )Ini ( )Umu ( )Uvimbe wa Ini ( )Kupooza ubongo ( )Pafu ( )Kuzimia ( )Kipindupindu ( )Matatizo ya Mgongo ( )Matatizo ya neva( )Figo
( )Kisukari ( )Degedege ( )Shida Ya Kuongea ( )Ujongwa wa Ngozi ( )Kibofu cha Mkojo
( )Machumbwichumbwi ( )Kifua Kikuu ( )Kuwa Mjamzito ( )Kuchelewa Kukuwa ( )Kusikia ( )Churua ( )Donda ndugu ( )Mdomo Ulioshikana
( )Maji kwenye Ubongo ( )Uvutaji Sigara ( )Rubela ( )Hemofilia ( )Homa ya baridi yabisi ( )Shinikizo la Damu
( )Uvimbe Mdomoni ( )Matatizo ya Ubongo ( )Oparesheni ya Moyo ( )Tezi ( )Ugonjwa wa Moyo/ Matatizo ya Kuzaliwa
Tafadhali eleza:
Sababu ya ziara ya leo:
Tafadhali eleza matatizo yoyote ya meno au matibabu ya shata, au toa maelezo mengine ambayo unadhani yanaweza kuwa muhimu katika huduma atayopewa mgonjwa:
UTHIBITISHO NA IDHINI YA MATIBABU
Mimi nathibitisha kuwa mimi ndimi mgonjwa au mzazi / mlezi wa mgonjwa aliyetajwa hapo juu na taarifa iliotolewa katika fomu hii ni ya kweli na sawa kwa ufahamu wangu. Mimi pia natoa idhini yangu kwa ajili ya mtoto wangu au mimi mwenyewe kupokea huduma na ukaguzi kamili wa kinywa na meno (ikiwa ni pamoja na picha ya eksirei itakayohitajika ) na kusafisha meno. Baada ya kushauriana, mimi nakubali aina zote za matibabu, dawa, na matibabu yaliyopendekezwa kwa ajili ya huduma za meno za mgonjwa aliyetajwa hapo juu. Mimi pia nafahamu ya kuwa mimi binafsi nawajibika kwa sehemu zozote za mgonjwa zinazoachwa mikononi mwangu. Mkataba huu umetengenezwa na Kool PC Smiles.
Sihihi: _____________________ Uhusiano na Mgonjwa (kama mgonjwa ni mtoto): Tarehe:
Sahihi ya Daktari wa Meno: Tarehe:
English英语译成Swahili斯瓦西里语: Tax Return Forms General field: 商务/金融 Detailed field: 法律：税与海关
原文文本 - English英语 Do you need to complete a tax return?
Due to competing demands, Diversitat are unable to offer tax help this year.
Any person who has worked in Australia between July 1st 2010 and June 30th 2011 must lodge a tax return with the Australian Tax Office. You will receive a Group Certificate from your employer that you have worked for and need to keep this until you do a tax return.
Diversitat has found a company called SJ Canny that will do tax returns from $75.00. The tax returns will be done by professional taxation agents who will make sure that your tax return is done properly. A tax agent from SJ Canny will be at the Northern Community Hub one day a week to help you with your tax return if we have enough people that are interested in using this service.
Please let your caseworker know if you are interested in having your tax return done this way so that we can arrange a day for the tax agent to come to the Northern Community Hub.
Keep in mind that you can claim the $75.00 fee as a refund on next year’s tax return.
If you do not want to use this service you can find an alternative taxation agent or, under certain circumstances, help is available from the ATO Tax Help Program. This program is only for wage and salary earners or those who have only received Centerlink payments. People who have an ABN cannot use this service.
The Tax Help Program is operated by volunteers and they will only see you by appointment. If you are eligible and would like to make an appointment please call one of the following numbers - please choose the one nearest to where you live.
• Corio 5275 4597
• Hamlyn Heights 5277 9027
• Lara 5282 2725
• Belmont 5243 8388
• Waurn Ponds 5243 2400
翻译文本 - Swahili斯瓦西里语 Je, unahitaji kukamilisha fomu za ushuru?
Kutokana na kuongezeka kwa kazi/mahitaji, Diversitat hawawezi kutoa usaidizi wa ushuru mwaka huu.
Mtu yeyote ambaye amefanya kazi Australia kati ya Julai 1, 2010 na Juni 30, 2011 lazima akamilishe fomu za ushuru na Ofisi ya Ushuru ya Australia. Utapokea Cheti cha Kikundi kutoka kwa mwajiri wako ambaye umemfanyia kazi na unapaswa kukiweka cheti hicho mpaka utakapo jaza fomu za ushuru.
Diversitat imepata kampuni inayoitwa SJ Canny ambayo itafanya/itajaza fomu za ushuru kwanzia dola ($) 75.00. Fomu za ushuru zitajazwa na mawakala wa kitaalamu wa utozaji kodi ambao watahakikisha kwamba fumo zako za ushuru zimejazwa vizuri. Wakala wa ushuru kutoka SJ Canny atakuwa katika Kituo cha Jamii ya Kaskazini siku moja kwa wiki ili kukusaidia wewe kujaza fomu yako ya ushuru kama tutakuwa na watu wa kutosha ambao watakuwa na nia ya kutumia huduma hii.
Tafadhali mweleze mfanyikazi wa kesi yako ili ajue kama una nia ya kujaziwa fomu za ushuru kwa njia hii ili tuweze kupanga siku ambayo wakala wa ushuru atakuja Kituo cha Jumuiya ya Kaskazini.
Kumbuka kwamba unaweza kudai ada ya dola ($) 75.00 kama marejesho ya ushuru ya mwaka ujao.
Kama hutaki kutumia huduma hii unaweza kutafuta wakala wa utozaji kodi mwingine au, kutokana na hali fulani, usaidizi unapatikana kutoka Programu ya Usaidizi wa Ushuru ya ATO. Mpango huu ni kwa ajili ya watu wa mapato ya ujira na mshahara au wale waliopokea malipo ya Centerlink peke yake. Watu ambao wana ABN hawawezi kutumia huduma hii.
Programu ya Usaidizi wa Ushuru inaendeshwa na wafanyakazi wa kujitolea na wao watakuona tu kwa miadi. Ikiwa unastahiki na ungependa kufanya miadi tafadhali piga simu kwa moja ya nambari zifuatazo - Tafadhali chagua moja ambayo iko karibu na unapoishi.
• Corio 5275 4597
• Hamlyn Heights 5277 9027
• Lara 5282 2725
• Belmont 5243 8388
• Waurn Ponds 5243 2400
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