The following is our policy.
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- Gladys Lamb
- 8 years ago
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Transcription
1 Thank you for choosing our office as your dental health care provider. We are committed to providing you with the highest quality dental care, so that you may attain optimal oral health. Everyone benefits when office and financial policies are understood. The following is our policy. Payment is due at the time services are rendered. We accept cash, personal checks, money orders, Visa, MasterCard, Discover, American Express and Care Credit. Returned checks will be subject to additional fees. Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services regardless of dental insurance. As a courtesy to you we will process all your insurance claims. We ask that you pay the deductible and co-payments, which is the estimated amount not covered by your insurance company at the time service is rendered to you. We must emphasize that this is only an estimate and all charges you incur are your responsibility regardless of insurance coverage. Insurance companies have a wide variety of rules, plan limitations, and exclusions that our office may not be aware of. Dental insurance is a benefit for the patient provided by their employer and the contract lies between the patient, employer and the insurance company. Unpaid balances over 30 days are subject to finance charges at a rate of 1.5% per month. Unpaid balances over 90 days are subject to being turned over to collections. We extend a 10% courtesy discount for our seniors 65 years of age and older. We extend a 5% discount on prosthetic services that are pre-paid in full. Acceptable form of payment is cash only. If you have insurance to be filed, we will file the claim on your behalf and the insurance company will reimburse you. All patients must provide a form of ID and Insurance card (if applicable) to be copied at the time of the appointment. We require personal contact telephone numbers as well as contact telephone number to use in case of an emergency. Cancellation and Late Policy: Your appointment time is reserved for you. If you are late for your appointment we may not be able to accommodate you. If you think that you will be late, please call as soon as possible so that we may advise you if your late arrival can be accommodated or if we will need to reschedule you. We maintain a very strict schedule and must insist that appointment times be respected. For cancellations we require 24 hour advanced notice or a cancellation charge will incur. An answer machine is available for messages left after business hours. Repeatedly missed appointments may result in dismissal as a patient. We thank you for the opportunity to serve your dental health care needs and welcome any questions you may have concerning your care or our policies. CONSENT I have read, understand and agree to the above terms and conditions. I understand that responsibility for payment for dental services rendered in this office for myself or my dependents is mine, due and payable at the time services are rendered. I further understand that a finance charge or collection charge will be added to any overdue balance. Signature (patient or responsible party) Print Name (patient or responsible party)
2 CONSENT TO THE USE AND DISCLOSURE OF THE HEALTH INFORMATION FOR THE TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS I hereby acknowledge receipt of a written notice of my privacy rights and I consent to DENTAL PROFESSIONAL ASSOCIATES, LLC using and disclosing my protected health information to carry out treatment, payment or healthcare operations. I understand and have been provided with a Notice of Privacy Practices, which provides a more. complete description of how my protected health information may be used or disclosed, I understand that I have the right to review the notice prior to signing this consent. I understand that DENTAL PROFESSIONAL ASSOCIATES, LLC reserves the right to change their notice and information practices and that I may obtain a copy of the revised notice by written request addressed to MICHAEL LAMB, DDS c/o DENTAL PROFESSIONAL ASSOCIATES, LLC, 1160 VARNUM ST., NE #006, WASHINGTON, DC I understand that I have the right to restrict how DENTAL PROFESSIONAL ASSOCIATES, LLC uses or disclose my protected health information to carry out treatment, payment or health care operations: that DENTAL PROFESSIONAL ASSOCIATES, LLC is not required to agree to the restrictions and; that DENTAL PROFESSIONAL ASSOCIATES, LLC is bound by restrictions to which it agrees. I request the following restrictions to how my health information is used or disclosed: I have the right to revoke this consent by notifying DENTAL PROFESSIONAL ASSOCIATES, LLC in writing, except to the extent that DENTAL PROFESSIONAL ASSOCIATES, LLC has taken action in reliance on my consent. Signature of patient or patient s representative Printed name of patient or patient s representative Relationship to patient or patient s representative s authority to act for the patient
3 Age Last First Initial of Birth n Male n Female If Child? Parent s Name How do you wish to be addressed? n Single n Married n Separated n Divorced n Widowed n Minor Residence - Street City State Zip Business Address Telephone: Res. Fax Cell Phone # Patient/Parent Employed By Present Position How Long Held Spouse/Parent Name Spouse Employed By Present Position How Long Held Who is Responsible for this account Drivers License No. Bus. Method of Payment: n Insurance n Cash n Credit Card Purpose of Call Other Family Members in this Practice DENTAL INSURANCE - 1ST COVERAGE Employee Name of Birth Relationship to patient Employer Name Yrs. Name of Insurance Co. Address Telephone Program or policy # Social Security No. Union Local or Group DENTAL INSURANCE - 2ND COVERAGE Employee Name Relationship to patient Employer Name Name of Insurance Co. Address Telephone Program or policy # Social Security No. Union Local or Group of Birth Yrs. CONSENT: I consent to th diagnostic procedures and treatment by the dentist necessary for proper dental care. I consent to the dentist s use and disclosure of my records (or my child s records) to carry out treatment, to obtain payment, and for those activities and health care operations that are related to treatment or payment. I consent to the disclosure of my records (or my child s records) to the following persons who are involved in my care (or my child s care) or payment for that care. Who may we thank for this referral Patient/Parent Social Security No. Spouse/Parent Social Security No. Someone to notify in case of emergency not living with you My consent to disclosure of records shall be effective until I revoke it in writing. I authorize payment directly to the dentist or dental group of insurance benefits otherwise payable to me. I understand that my dental care insurance carrier or payor of my dental benefits may pay less that the actual bill for services, and that I am financially responsible for payment in full of all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payment of services not paid, by my dental care payor. I attest to the accuracy of the information on this page. REGISTRATION Patient s or Guardian s Signature
4 Last First Initial of Birth CIRCLE THE APPROPRIATE ANSWER, IF YOU DON T KNOW THE CORRECT ANSWER PLEASE WRITE DON T KNOW ON THE LINE AFTER THE QUESTION COMMENTS 1. Physician s Name Address Tel: 2. Are you under a physician s care?...n YES n NO Since when Why 3. When was your last complete physical exam? 4. Are you taking any medication or substances?...n YES n NO (If yes, please list medications in comments section or on the back of this form) 5. Do you routinely take health related substances? (Vitamins, herbal supplements, natural products) n YES n NO 6. Are you allergic to any medications or substances? (please list)...n YES n NO 7. Do you have any other allergies or hives?...n YES n NO 8. Do you have problems with penicillin, antibiotics, anesthetics or other meds?...n YES n NO 9. Are you sensitive to any metals or latex?...n YES n NO 10. Are you pregnant or suspect you may be?...n YES n NO 11. Do you use any birth control medications?...n YES n NO 12. Have you ever been treated for or been told you might have heart disease?...n YES n NO 13. Do you have a pacemaker, an artificial heart valve implant, or have been diagnosed with mitral valve prolapse?...n YES n NO 14. Have you ever had rheumatic fever?...n YES n NO 15. Are you aware of any heart murmurs?...n YES n NO 16. Do you have high or low blood pressure?...n YES n NO 17. Have you ever had a serious illness or major surgery?...n YES n NO If so, explain 18. Have you ever had radiation treatment, chemo treatment for tumor growth or other condition?...n YES n NO 19. Have you hever taken Fosamax, Zometa, Aredia or any other oral or intravenous treatment (bisphosphonates) for bone tumors, excessive calcium in your blood, or osteoporosis? n YES n NO 20. Do you have inflammatory diseases, such as arthritis or rheumatism?...n YES n NO 21. Do you have any artificial joints/prosthesis?...n YES n NO 22. Do you have any blood disorders, such as anemia, leukemia, etc?...n YES n NO 23. Have you ever bled excessively after being cut or injured?...n YES n NO 24. Do you have any stomach problems?...n YES n NO 25. Do you have any kidney problems?...n YES n NO 26. Do you have any liver problems?...n YES n NO 27. Are you diabetic?...n YES n NO 28. Do you have fainting or dizzy spells?...n YES n NO 29. Do you have asthma?...n YES n NO 30. Do you have epilepsy or seizure disorders?...n YES n NO 31. Do you or have you had venereal or any sexually transmitted disease?...n YES n NO 32. Have you tested HIV positive?...n YES n NO 33. Do you have AIDS?...n YES n NO 34. Have you had or do you test positive fowr hepatitis?...n YES n NO 35. Do you or have you had T.B.?...n YES n NO 36. Do you smoke, chew, use snuff or any other forms of tobacco?...n YES n NO 37. Do you regularly consume more than one or two alcoholic beverages a day?...n YES n NO 38. Do you habitually use controlled substances?...n YES n NO ANEST. 39. Have you had psychiatric treatment?...n YES n NO 40. Have you taken any prescription drugs fenfluramine, fenfluramine combined with phentermine (fen-phen), dexfenfluramine (redux), or other weight loss products?...n YES n NO 41. Do you have any disease condition, or problem not listed? If so, explain MED. ALERT 42. Is there anything else we should know about your health that we have not covered in this form? 43. Would you like to speak to the Doctor privately about any problem?...n YES n NO I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE PATIENT S/GUARDIAN S SIGNATURE DATE DENTIST S SIGNATURE DATE MEDICAL HISTORY
5 Last First Initial of Birth 1. Purpose of initial visit 2. Are you aware of a problem? 3. How long since your last dental visit? 4. What was done at that time? 5. Previous dentist s name Address: Tel. 6. When was the last time your teeth were cleaned? MARK THE APPROPRIATE ANSWER. IF YOU DON T KNOW THE CORRECT ANSWER, PLEASE WRITE DON T KNOW ON THE LINE AFTER THE QUESTION. 7. Have you made regular visits?...n YES n NO How often: 8. Were dental x-rays taken?...n YES n NO 9. Have you lost any teeth or have any teeth been removed?...n YES n NO Why? 10. Have they been replaced?...n YES n NO 11. How have they been replaced? a. Fixed bridge Age b. Removable bridge Age c. Denture Age d. Implant Age 12. Are you unhappy with the replacement?...n YES n NO If yes, explain: 13. Would you like to know about permanent replacements?...n YES n NO 14. Have you ever had any problems or complications with a previous dental treatment?...n YES n NO If yes, explain: 15. Do you clench or grind your teeth?...n YES n NO 16. Does your jaw click or pop?...n YES n NO 17. Have you experienced any pain or soreness in the muscles of your face or around your ear?.n YES n NO 18. Do you have frequent headaches, neck aches or shoulder aches?...n YES n NO 19. Does food get caught in your teeth?...n YES n NO 20. Are any of your teeth sensitive to: n Hot? n Cold? n Sweets? n Pressure? 21. Do your gums bleed or hurt?...n YES n NO When? 22. Do you experience dry mouth?...n YES n NO 23. How often do you brush your teeth? When? 24. Do you use dental floss?...n YES n NO How often? 25. Are any of your teeth loose, tipped, shifted or chipped?...n YES n NO 26. Are you unhappy with the appearance of your teeth?...n YES n NO 27. How do you feel about your teeth in general? 28. Do you feel your breath is offensive at times?...n YES n NO 29. Have you ever had gum treatment or surgery?...n YES n NO What? Where? When? 30. Have you had any orthodontic work? 31. Have you had any unpleasant dental experiences or is there anything about dentistry that you strongly dislike? 32. Do you have any questions or concerns?...n YES n NO COMMENTS ANEST. MED. ALERT I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE PATIENT S/GUARDIAN S SIGNATURE DATE DENTIST S SIGNATURE DATE DENTAL HISTORY
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