UNIVERSITY PEDIATRIC DENTISTRY ASSOCIATES

DOB:

Riley Hospital for Children IU Health | ROC | Pediatric Dentistry 705 Riley Hospital Drive, Room #4205

EDR#:

NAME:

Indianapolis, IN 46202-5109 317.944.3865 office | 317.944.9653 fax

DATE:

Iuhealth.org/riley/dental-health

PATIENT REGISTRATION DATA University Pediatric Dentistry Associates zumhngiat nak langhter in na ngakchia kaachung ngandamnak  zohkhenhpiak ding ah na thim i kan ilawm. Nangmah bawmhchanh hi kan ilawmh nak a si.  Na ngakchia kong kan chim tuah

 

 

Mizaw Min: _____________________________________________ 

Chuah ni: ______________________________________________ 

Mizaw Address: ___________________________________________  

Nu/Pa:   Nu   Pa 

Patient Address:___________________________________________ 

Na duh deuh mi holh:________________________________________ 

Khua:_____________________________________________________ 

Student:   Yes           No 

Minung phun (race):_____________ 

School:_______________________ 

Ramkulh:___________________________  ZIP:____________________  Insurance A Ngeih Mi Kong  Aho he dah mizaw cu an umṭi?_________________________________  Insurance Co min:______________________________________  Chimh a herh mi kan chim dih law pakhatkhat hi mizaw pehtlaih nak  ca ah thim. 

Rian a pe tu:_________________________________________   Insurance a ngei tu:_________________________________________ 

  Inn Phone:______________________________________ 

Mizaw he an ipehtlaih ning:      Nu le pa          Amah          Nupi/va 

  Cell Phone:________________________________________ 

Insurance Group ID #:_______________________________________   

 Phone dang:______________________________________ 

Subsriber’s ID #:____________________________________________   

Na ngakchia chungkhar kong kan chim tuah

Zohkhenh tu min:____________________________________________   Mizaw he an ipehtlaih ning:____________________________________  Address:__________________________________________________ 

Nu/Pa:   Nu    Pa 

Address:__________________________________________________ 

Aa um maw:  Ṭhen mi      Kop ngei  Mipaak      Va i thitaak mi 

Chuah ni:__________________ 

Khua:______________________________________________________  Na duh deuh mi holh:________________________________________  Ramkulh:_________________________  Zip:____________________ 

Email:____________________________________________________ 

 

 

 

 

 

 

 

 

Chimh a herh mi kan chim dih law pakhatkhat hi hi account pehtlaih nak  Nu le pa i naa serh mi midang, phung ning i zohkhenh tu, le chuahpi  ca ah thim.  unau vialte kong chim.    Inn Phone:______________________________________ 

 Zohkhenhtu (hna)  Min:_______________________________________ 

  Cell Phone:________________________________________ 

 Chuahpi u le nau  Min:________________________________________  

  Phone dang:______________________________________ 

 Midang                Min:_________________________________________ 

 

 

 

 

 

 

 

 

 

 

 

 

Mithanh nak: Appointment pohpoh ah phung tang i zohkhenh tu a um ve hrimhrim ding hi kan zung nih a hauh.  Mithanhnak: Kan zung i pekchanh mi thlopbul nak vialte ca tangka liam ding kong i mawhphortu ding ah appointment hmaasa bik i  mizaw a ratpi tu phungtang zohkhen tu le kan Office Patient Agreement min a thu tu hi kan tarh lai. 

Zohkhenhtu Minthut:________________________________________________________    Nithla:____________ Acaan:________  Form #UPDDR215 Rev 12/2013

U Y S T C Y E R T S R T A R T S E A C V T O D N N YP S TY CD YA ES RY TE SIIIT RIIIC TR AT RS TR ST ER AT CIIIA VE TIIIS OC DIIIA NT UN NIIIV PEEED DEEEN ASSSSSSO Riley Hospital for Children IU Health | ROC | Pediatric Dentistry 705 Riley Hospital Drive, Room #4205 Indianapolis, IN 46202-5109 317.944.3865 office | 317.944.9653 fax Iuhealth.org/riley/dental-health

DOB:

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NA: LC:

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OFFICE POLICY University Pediatric Dentistry Associates zumhngiat nak langhter bu in na ngakchia kaachung ngandamnak zohkhenhpiak ding ah na thim i kan ilawm. Nangmah bawmhchanh nak nawl kan ngeih hi kan duh ngaingai i kan ilawm taktak. Atang i hi kan zung kong, a phung kong le pawlisi kong an si. Appointment Kong Ah • Mizaw hi appointment lawng in zoh an si. Appointment ser a si nak chan cu, na ngakchia a ṭ ha bik i kan hramhthlop khawh nakding ah le a ṭ ha chuahter kan duh ruang ah caan a za tawk izuah kho seh ti ah a si. Appointment leet (khensel) nakding ah ahlankan in atlawm bik suimilam 24 tal a herh. Mahti tuante i caan leet cia tik ah mah caan sung cu herh a ngei mi ngakchia dang pek khawh a si cang. Appointment oi tam tuk tlolh/leet ah cun appointment dang kan in pe ti men hna lai lo. • Phung tang i a pa/nu a si mi asilo ah a zohkhenh tu a si mi hrimhrim nih mizaw cu aa piah tik poh ah ratpi lengmang ding a si lai. Mizaw a rak ṭ hi tu cu mi hngah nak ah a um lai i, mizaw an zoh i an hramh a dih cikcek hnu, sibawi i a thlah hnu tiang hngah ṭ hiuṭ heu ding a si lai. Phung tang i zohkhenh tu nih a/n ratpi a si lo ah cun mah ngakchia cu mah caan serpiak mi chung i hramh ding zong zohhramh ṭ han lo in a kir ko lai. • IU Health hruang chung pohpoh ah, mizaw hngah nak hmun ah si seh, hmun dang ah si seh, ei le din le kuakzuk a ngah lo, eidin nak hrimhrim i ser mi hmun ti lo ah cun. Ei le din isum in mah si-inn phung zulh cu rak kan bawm ve tiah kan in nawl. TANGKA HE PEHTLAI IN • Mizaw zohhramh a si sin ah khin tangka liam a cu colh. Mah ah cun mah i chap a hau mi, bawmhnak i a khuhchilh lo mi hramh nak, le a si awk a si mi le a si tawn mi leiba taang vialte an itel. Nangmah siarem nak ah phaisa fang si seh, chek si seh, credit cards si seh kan cohlan ko. • TANGKA LIAM RIAN: ADIHDONGH NAK I TANGKA KONG AH MAWH A PHOR DING CU MIZAW NGAKCHIA NU LE PA /ZOHKHENH TU, HI KONG AH KEIMAH NIH TANGKA KA LIAM LAI TI I ATANG I MINTHUT BANTUK IN BIA AA KAM MI AN SI LAI. Nu le pa i an hna a tlak leen zong ah mah mizaw hramhthlop nak ca i a dih mi kong ah midang aho hmanh chap in kan zung nih leiba kan cop hna lai lo. • LEIBACA: Liam rih lo mi tangka taang na ngeih ah cun atik ah theihter nak bia kan in chuah te lai. Na bat mi a pumpaluk cu leibaca kan in kuat in ni 30 chung ah cham dih ding a si lai. • HA INSURANCE: Insurance phung, hmuhtin ding zat, liam ding zat, tehna aa thlen lengmang ca ah insurance i na hmuh ding mi hi ahrawnghraang lawng in kan tuak khawh. Kannih zung cu insurance pawlisi vialte a pe tu ah aa tel lo. Biahal awk fiangfai te na ngeih ah cun na insurance na tuah nak hna kha dengteo in hal ko hna. • HA INSURANCE HLAM NING: Na ha ca insurance hlam kan in bawmh ko lai; asinain, si lei insurance hlam ning kong tu ah cun tlawmte lawng kan in bawmh khawh lai. Hmaante le zokzokte i na ha insurance kan hlam khawh nakhnga naa piah tik pohpoh ah na ha insurance caphel (card) te kha na rak iken lengmang lai. • MEDICAID le NGAKCHIA DAM NAK PLANS PAWL: Indiana Health Care Plans (Medicaid, Hoosier Healthwise), le ngakchia ha piah nak i an ser mi pawl kan cohlan. An card copy asilo ah ahlan i nawlpekcang nak rak iken lengmang ding a si lai, ningcangte i bill khawh nak ca ah. Insurance ngeih nak a piah kho lo mi maw, ahlan i cohlan cang nak a ngei lo mi maw, bawmh nak hmuh khawh nak a ngeih lo lio a si mi maw, an si ah cun an ipiah man anmah kan cawh men hna lai. Spenddown aa tel mi plan phun a la mi cu Medicaid phung le a khuhchilh zat an khiah mi phung ning in liam awk tuakpiak an si lai. Medicaid i a khulchilh (cover) lo mi hramhthlop nak an laak ah cun zohhramh an si ni lila ah an liam awk hnga tlingte le adihlak in liamter an si lai. Medicaid phung ning ah ipiah nak nawl a ngei rih mi cu an ipiah nak i a cover mi hramhthlop nak ah IHCP nih liamvo cawh an si lai lo.

ṭ elifawn azei poh ah kan in chawnh ko lai. Na kutput phone zong ah kan in chawnh ko lai i a dihek cu nangmah cung ah a tlung lai. Text message si seh, e-mail zong kan in kuat ko lai, e-mail address na kan pek mi ah. Kan in chawnh ding ning ah cun awkhumh cia/serchom aw i chawnh, cu cu kha kha hmet law ti bia, cabawm cakuat, text message cakuat, cun minung le minung ichawnhbiak phun zong a si ko lai. HIPAA & MIZAW PUMPAK KONG HUMZUAL NAK: Kan zung hi HIPAA, HITECH, le Patient Privacy ti mi Mizaw Pumpak Kong ca i ser mi phunglam a zul mi a si. Mah phunglam chung i aa tel mi kong hngalh na duh ah cun IU Health Patient Rights khi rel ding a si lai. Hngalh awk: Mahhi theihternak hi kan zung ah laak khawh awk in a um. HRAMHTHLOP NAK CA NAWL PEK NAK MAWHPHORH NAK KONG IKAM NAK Mah hi bia fek in ka chim: Keimah hi mahhi form i a um mi mizaw i phungtling zohkhenh tu asilole cu aiawh cu ka si. Mahka i ka chim mi kong hna hi keimah hngalh tawk ah a dikhmaan mi lawngte an si. Mah cu athup in chiah a si lai i, hramh lio mi ngakchia kong ah si seh, a zohkhenh tu kong ah si seh, a um nak kong ah si seh, adihlak kong ah si seh, aa thleng mi um ai kon nan zung i thanh ding hi keimah rian a si lai. Mah Patient Rights and Privacy ti mi mizaw tinvo le a pumpak kong phung hi zohthlir ṭ han nak nawl pek ka si ti ka cohlan. Ka ngakchia i a herh mi ha kong hramhkhiat nak pohpoh tuahpiak ding in ha zung rianṭ uan pawl nawl ka pek hna. Indiana University School of Dentistry chung i laisen ngei ha lei rianṭ uan nih hramhthlop nak hi an pek khawh ti ka hngalh. Hramhthlop ning kong, x-rays, le hmanthlak azei poh, thiam chimh nak ca ah le thil dothlatnak ca ah le science lei cachuah nak ah hman nak nawl ka’n pek hna. Mah kong hi coawk a him nak ah thlah ding in nawl ka pek i cu lo ah cun keimah liamh ding ka si lai. Indiana Healthcare Coverage Plans (Indiana Medicaid) phung nih hmuh awk rua a hmu ding a si mi chungtel pawl ca ah a kham a si dah lo ah cun, ha lei i hmuh awk ka ngeih mi a um zong um lo zong ah, mah hramhthlop nak account i cham awk rua pohpoh cham ding hi keimah rian a si ti ka hngalh. Keimah i pek hau a si sual ah cun, leiba cawh nak ca i a herh mi rian ṭ uan nak man vialte, biacaih zung i taza cuai nak man le sihni hlan nak man vialte le mah lawng hmanh si lo adang zong, keimah nih ka liam dih ko lai tiah ka hna a tla. Atang i ka minthut nih hin mah a cung i ka hnatlaknak vialte cu ai a awh tiah bia fek in ka chim.

Zohkhenhtu min

____________________

_________

Mizaw he ipehtlaih ning

Zohkhenhtu minthut

Nithla / Caan

Tehte

Nithla / Caan

• CHAM DING CAAN I CHAM LO AH: Kan leiba coptu he ahlankan in khuakhannak nan ngei cang dah a si lo ah cun, leiba cawh nak cachuah kan tuah hnu ni 30 ah na leiba cu cham an cu cang. Ni 31 hnu tiang i a taang mi leiba cu leiba taang ah ruah an si. Mah bantuk leiba taang cu a tawlrel nak man he cawh chih a si kho, cun leiba cop tu sin zong ah kuat a si kho, a pahnih zong a si kho. Na sizung herh kan in tuahpiak khawh nak ah si seh, na bat mi kan in cawh khawh nakhnga ah si seh, ṭ elifawn in kan in chawnhbiak men lai. Na sizung account he aa pehtlai mi Form #UPDDR216 Rev 12/2013

U Y S T C Y E R T S R T A R T S E A C V T O D N N YP S TY CD YA ES RY TE SIIIT RIIIC TR AT RS TR ST ER AT CIIIA VE TIIIS OC DIIIA NT UN NIIIV PEEED DEEEN ASSSSSSO Riley Hospital for Children IU Health | ROC | Pediatric Dentistry 705 Riley Hospital Drive, Room #4205 Indianapolis, IN 46202-5109 317.944.3865 office | 317.944.9653 fax Iuhealth.org/riley/dental-health

DOB:

EDR:

NA: LC:

DATE:

SI / HA LEI TUANBIA Mizaw Min: Chuah nak khua le ramkulh min: Zohkhenh tawn tu sibawi min: Sibawi Address: Sibawi Phone: Naa piah hmanung bik ni:

Chuah nithla: Minung phun (race): Ha sibawi hmasa-u: Ha sibawi Phone: Ha naa piah hmanung bik ni: Ha X-rays hmanung bik ni:

Ha Tuanbia: Zei ruah bik ah dah na rat? Mizaw cu a faak maw? Faak A kaa, a ha, a kharuh ah hliamhma a ngei maw?  Ngei Zei ti a ding mi dah a si?:  Mah tikhor ti te Mizaw cu  Hnukdinh mi maw  Thawl hnuk dinh mi Zei can dan ah dah a ha aa ṭ awl tawn? Mizaw cu… Yes / No   A kutdong aa zu maw   Pesifiar a hmang maw Aa Hramhthlop Ning: Mizaw cu sibawi i a hramh lio mi a si maw? Iziak lo mi a ngei maw? Si din lio mi a ngei maw? Si an dinter mi min:

Mizaw cu aa hlai maw, sizung ah a um bal mawi? Si-inn I A ngeih mi:

Nu/Pa: Nu Pa Tungkhaan:_______ Rih____

Faak lo Fianter: Ngei lo Fianter:  Khuapi ti, Zei khua: Kum zeizat a ti tiang? Hnukdinh: Bawmh chom in Bawmh lo in

Cu lo: Thawlhnuk dinh: Zei can dan ah dah a ha aa coih?

Yes / No   A tin aa seh maw   Holh aa harh maw

 

Yes / No  A hacang a rial maw  A kaa in a thaw a chuah maw

YES YES YES

NO Fianter: NO Fianter: NO Si a din lio mi le aa hramh nak ttial dih. Catlap khattelei zong ah hmun a um rih A din zat: Oi zeizat lengmang dah a din:

YES

NO Zeitik ah:

Mizaw cu atang i hi a ngei (bal) maw: Yes / No   Ichuahpi mi lung zawtnak   Lung hlai   Heart Murmur [Lung aw hmaan lo]   Thitha saan (High BP)   Hliahcaang fah zawtnak   Khuhhrin/Thawchuah lei bonlo   Thluak rak khawn ruang i ṭ awnhṭ aih   Hnuhdawh/Tomkuaih/Hruhmolh   Thiam khawh lo/chawnhbiak awk ṭ hat lo   Hawi lawh lo, mikeel si lo, mihrut sii   Lung hmunh lo, lung cawl tuk [ADD/ADHD]

A ruang:

Yes / No   Mit/Hna ṭ hat lo   Thichuah bonlo   Sickle Cell Trait/Disease   Thi tlawm/derthawm   Kal zawtnak   Thin zawtnak   Zunthlum   Tit/Hliah/Ruh fah   Hrum/gland ṭ hat lo   Cuar ṭ hat lo / tak ṭ ial / Kik   Rengh, ṭ han khawh lo

          

          

Yes / No Ei lei bonlo Thla tling lo i chuah Raidawnsi Hepatitis A, B, C [thin phin] Thi rawnh HIV/AIDS Sendeh phar zawt (chickenpox) MRSA TB / Cuap zawtnak Cawlcangh khawh set lo Adang:

Acung i hi ka hngalh tawk ah an hmaan tiah bia fek ka chim. Puangthang lo te in tawnghtham a si lai i hi mizaw ngandam nak kong i aa thleng mi a um ah cun hi zung theihter hi keimah rian a si lai. Mah mizaw ngandamnak kong hi healthcare providers dang sin zong ah hi mizawh ha hramhthlop nak ca i a herh ning in thlah khawh a si ko tiah nawl ka thlah. Zohkhenhtu Minthut: Resident Signature:

Mizaw he an ipehtlaih ning: Nithla:

Acaan: Form #UPDDR217 Rev. 12/2013