Smiles at Summer Hill Dental and Summerlyn Dental Care

Transcription

1 Smiles at Summer Hill Dental and Summerlyn Dental Care New Patient Interview 1. Would you be willing to tell me why you decided to select a new dental office and why you choose Summer Hill/ Summerlyn Dental Care? 2. What do you most look for from a dental office? 3. On a scale of 1-10, what is your comfort level for going to the dentist? One being least comfortable, 10 being really comfortable. 4. What are the positive or negative aspects of your dental health? 5. Can you eat anything you want, whenever you want? 6. What are your goals for your dental health? 7. Could you tell me how you feel about your smile? (shape/color of teeth) Page 1 of 11

2 A WORD TO OUR PATIENTS WITH INSURANCE During the past decades, dental benefits plans have become an integral part of healthcare planning for many families. Dental benefit plans are made available to employees or members through companies, unions, and associations, and may vary considerable from one plan to the next. Your employer has purchased a specific benefit plan from literally hundreds of combinations available. Your company decides how much it wishes to pay for benefits and chooses a plan that tries to meet as many of its employees' needs as possible. The range of benefits depends on what the purchaser wished to offer employees or members. Come plans may cover as little as 30 percent or as much as 100 percent of dental services, such as orthodontics, while other plans cover a full range of dental services. The type of treatment you need and receive from us is based upon our professional judgement and not on your coverage by a dental benefit plan. We will not compromise our recommended treatment in order to accommodate an insurance program's maximum benefits that may be considerable less than optimal. We are more than happy to discuss a treatment plan's advantages and disadvantages with you, thereby involving you, rather than your insurance company, in the decision making process. As a courtesy to you, our staff will expedite insurance claims electronically and complete pre-estimates if they are required. Please remember that the financial obligation or dental treatment is between you and this office. The insurance company is responsible to you and not the office. We will help you in every way in filing your claims, handling insurance queries, processing follow-ups or locating lost claims. No question is too small for you to ask, whether it is about your treatment, benefit plan, or statement. We are here to help you. If you have any questions or concerns, please do not hesitate to ask. Sincerely, Summer Hill/ Summerlyn Dental Team Page 2 of 11

3 Insurance Express Check Out Form Patient s Name: Home Phone # Address: Cell Phone # Financial Policy With the introduction of the new Health Privacy Act and the diversity of dental benefit packages, the maintenance of accounts with a zero balance is difficult due to the uncertainty of what your insurance payments will be. It has been time consuming for us to continually collect or refund balances remaining, after insurance payments are received. We would rather invest our time ensuring that optimal dental care is given. We want to offer our new patients flexibility in paying for their dental treatment with the following options. [ ] OPTION 1 Fee for Service This option allows you to be in control of your insurance benefits, by paying in full at each appointment for treatment and being reimbursed directly by your insurance company. This will enable you to keep personal records of all dental records of all dental transactions, all insurance reimbursements, track maximum allowable benefits and you will be more aware of what your plan does not cover. You will not have to worry about having outstanding account balances with us and you will not have to come in to collect monies that we may owe to you. When insurance companies are reimbursing patients, payment usually takes one to two weeks to be received, especially if your plan accepts electronic dental claims. If required, we will send electronic claims for you at each appointment. [ ] OPTION 2 VIP Express Checkout Our VIP Express Checkout Program allows us to continue to offer you the convenience of using your insurance plan as a form of direct payment. We will require your credit card number and signature to issue a credit or debit memo to your credit card number for any over and under payment once your insurance portion has been received. You will be notified by phone or mail if any charge or credit is in excess of $ Any claim not paid by your insurance company within 30 days, will be automatically put through on your credit card, and receipt for this transaction will be mailed with a paid statement. Cancellation Policy Please notify us 48 hours in advance if you are unable to keep your appointment, otherwise $50.00 cancellation fee will be applied to your account. PATIENT AGREEEMENT I agree to the financial responsibility for the Out of Pocket Portion and Balance not covered by Insurance. I authorize Summer Hill/ Summerlyn Dental to Keep my signature on fille and issue a credit or debit memo to my credit card amount for any over and under payment once my insurance portion has been received. I will be notified by phone or mail if any charge or credit is in excess of $ I give my permission for any claim not paid by my insurance company within 30 days, to be automatically put through on my credit card. A receipt for this transaction will be mailed with a paid statement. PAYMENT METHOD Visa [ ] Mastercard [ ] American Express[ ] Credit Card #: Name on Card: Expiry Date: Signature: Signature of Patient Date DD/MM/YYYY Page 3 of 11

4 NEW PATIENT CONSENT FORM Professional Teeth Whitening for Life Professional Teeth Whitening for Life is a courtesy and a privilege of Summer Hill/ Summerlyn Dental patients. This program is extended to patients who have proven themselves as individuals who take their oral hygiene and general dental health seriously. We believe it is extremely important to maintain recommended hygiene care appointments and receive necessary treatment to maintain a healthy and beautiful smile. In fact, patients who maintain regular hygiene appointments and receive recommended treatment spend less money on dental care (on average) than those who only see the dentist when they perceive a problem exists. All too often, peop0le who wait until there is a problem have irreversible damage to their gums, teeth, and/or jaw. We pride ourselves on the smiles that leave our practice. We also pride ourselves on knowing our patients are maintaining the best possible oral health. Professional Teeth Whitening for Life was developed as a program for those patients that are already taking their dental health seriously, and as an incentive for those who need a little help keeping up their dental care. The Patient will receive custom made, professional, take home whitening trays for personal use. This privilege does require some rules, restrictions, and regulations. Below is a brief description of the qualifiers for this program. Please read through them carefully. You will also receive a copy of our Appointment Cancellation Policy. Please review the policy and sign below, acknowledging receipt and understanding of compliance of said policy. Professional Teeth Whitening for Life is a program from us to you, we insist that all rules and regulations are followed in order to receive and continue to receive this benefit. Should any of the rules or regulations fail to be met, you will immediately be disqualified from the program until you have successfully met all of the qualifying rules for a minimum of twelve months. Activation Rules and Regulations: 1. Must be at least 18 years of age. 2. Must complete initial hygiene cleaning, xrays, doctor's exam, and book appointments for six month re-care. 3. Must comply with minimum required dental care as per treatment planned by doctor*. 4. After all necessary dental treatment has been completed; patient will have impressions taken for professional whitening system. 5. Upon next appointment, patient will receive Professional Teeth whitening package**. 6. Must comply with appointment cancellation policy. Lifetime Maintenance Rules and Regulations: 1. Must maintain minimum continued care as per treatment planned and appointed by Summer Hill/ Summerlyn Dental, its doctors, and team*. 2. Must maintain continued hygiene care 3. Must comply with all Summer Hill/Summerlyn Dental policies regarding payment and broken appointments. Must not have any outstanding bills with Summer Hill Dental Must have at least six month patient history without any broken appointments or late arrivals. 4. A maximum of one whitening solution refill will be rewarded at each re-care appointment, or twice annually. 5. Lost or destroyed custom whitening trays will be replaced at a cost of $50.00 to patient. *All patients will receive their whitening package upon completion of all necessary dental treatment as determined by the dentist. Should no dental Treatment be required to maintain healthy teeth and gums, the total whitening package will be received upon completion of first hygiene appointment. Minimum gum and teeth health required to receive professional whitening in order to prevent complications that may arise with unhealthy teeth and gums. This program is non-transferable and is valid as long as Dr. Baraz owns Summer Hill/ Summerlyn Dental. ** New patients may activate Professional Teeth Whitening for Life membership upon first visit if the doctor determines the patient's mouth is healthy. Disclaimer: Summer Hill/ Summerlyn Dental, its doctors and team have the right to refuse offer if deemed necessary based on patient health conditions, misuse, abuse, or any other factor deemed necessary to void offer. I, hereby certify that I agree to the terms and conditions outline above. I also acknowledge receipt of Summer Hill Dental's Appointment Cancellation Policy. I understand that Professional Teeth Whitening for Life is a privilege only bestowed to individuals who meet and maintain all of the rules and regulations pertaining to said program. Signature Date: Page 4 of 11

5 Facts every insured patient needs to know You may be asked to provide the following information when calling your insurance company. Patient s Name: Date: Insurance Company: Telephone: Name of Subscriber: D.O.B. Employer: S.I.N. Policy No: Certificate No: Division No: Questions you should ask about your dental coverage What is the annual maximum allowed per patient? What is the anniversary date of the policy? i.e. Jan 1 st (Calendar Year) or benefit year? Is there an annual deductible? If yes, how much is it? Per Person $ Family Mas $ What year s Fee Schedule are dental benefits paid on? How many units of scaling and/or root planning are covered? Scaling Units per calendar year Scaling Units per rolling 12 months Scaling Units per benefit year How many Recall appointments are allowed annually? every 6 months every 9 months other What percentage of coverage is allowed for the following: Diagnostic % Preventive % Restorative % Endodontic % Periodontal % Major % Major: Crown and Bridge Yes or No Dentures Yes or No Extraction Clause Yes or No (Does a tooth have to be removed while insured?) Are resins covered in molar teeth? Yes or No What is the annual maximum for major treatment? Is Endodontic and/or Periodontal treatment classified as basic or major treatment? What amount of the Maximum is used to date for the current year? $ When was the last New Patient or Complete Oral Exam Done? When was the last Recall Exam Done? When was the last Full Mouth Series or Panorex taken? Page 5 of 11

6 You are responsible for keeping your insurance info current. Please notify us of any changes to your dental coverage Welcome to our Dental Office The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor patient confidentiality. Please fill in the entire form PERSONAL INFORMATION Dr. Mr. Mrs. Miss. Ms Name: Name you would like to be called: SIN# Date of Birth (DD/MM/YYYY) Home Tel: Office Tel No: Address: APT# City Postal Code: Physician: Previous Dentist: Physician s Phone No: Why did you decide to change dental offices? How did you hear about us? INSURANCE INFORMATION (1 ST ) Name of Insured if different from above: Insurance Co: Birthdate of Insured (DD/MM/YYYY) Division if Applicable Policy/Group Employer: Certificate ID# Do you have secondary insurance? INSURANCE INFORMATION (2NDARY) Name of Insured if different from above: Insurance Co: Birthdate of Insured (DD/MM/YYYY) Division if Applicable Policy/Group Employer: Certificate ID#: EMERGENCY CONTACT Name: Relationship: Tel No: MEDICAL HISTORY Are you being treated for any medical condition at the present or have been treated with the last year? If yes, please describe: When was your last medical check up? Has there been any change in your general health in the past year? Are you taking any medications or non prescription drugs of any king? If yes, please list them below: Drug: Reason: Drug: Reason: Drug: Reason: Do you have any allergies? If yes, please specify Have you had an unusual reaction to any drugs or medicines? Penicillin Sulfonamide Aspirin Codeine Local Anesthetic Other Have you ever taken cortisone or steroid medications? Do you have any sinus problems? Do you have or have you ever had any heart problems? Do you have a pacemaker? Do you have or have you ever had a heart murmur, mitral valve prolapse or rheumatic fever? Do you or have you ever had jaundice, hepatitis or liver disease? Do you have a bleeding problem or bruise easily? Page 6 of 11

7 Do you have any conditions that could affect your immune system? Eg: Aids, HIV Infection, Leukemia etc. Do you smoke? If yes, how much? Have you ever been hospitalized for any serious illnesses or operations? MEDICAL HISTORY CONTINUED Do you have any prosthetic or artificial joints? Do you have or have you ever had any of the following? Chest Pain/Angina Heart Attack High Blood Pressure Drug/Alcohol Dependency Tuberculosis Arthritis Emphysema Epilepsy Thyroid Disease Diabetes Asthma Stroke Stomach Ulcers Cancer Kidney Disease Psychiatric Disorder Chemo/Radiation For Females: Are you pregnant or breast feeding? Any other conditions or problems of which the dentist should be aware of? If yes, please list: DENTAL HISTORY When was your last dental visit? When did you last have dental xrays? How often do you brush your teeth? How often do you floss your teeth? Have you been seeing a dentist regularly? Do any of your teeth ache? Have you ever been advised to take antibiotics before dental appointments? Do your gums bleed when you brush? Do you have any pain when you chew? Do you feel that you have bad breath? Have you ever been in a motor vehicle accident or experienced any blows to your jaw? Have you ever had a dental implant surgery? If yes, who performed the implant surgery and when was it done? Are you being followed up by a dental specialist? If yes, provide the specialist and reason: Please list anything else not mentioned above regarding your past dental history: GENERAL CONSENT STATEMENT I certify that I have read, understood and accurately completed the personal, medical and dental histories, to the best of my knowledge, and not knowingly omitted any information. This information has been reviewed with me, and I have had the chance to ask questions and to receive answers regarding any medical and dental histories. I authorize the dentist to perform necessary diagnostic procedures and treatment, including general and local anaesthetic, as required, to achieve the proper level of dental care. I understand that I am financially responsible to the dentist for the dental services provided even if my insurance may not be all inclusive. Signature of Patient Date (DD/MM/YYYY) Page 7 of 11

8 Dentist Signature Date (DD/MM/YYYY) PATIENT CONSENT FORM FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION Privacy of your personal information is an important part of our office providing you with quality dental care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and transparent as possible about the way we handle your personal information. It is important to us to provide this service to our patients In this office, Dr. Zaid Baraz acts as the Privacy Information Officer. All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have discussed to us. They are all trained in the appropriate uses and protection of your information. Attached to this consent form, we have outlined what our office is doing to ensure that: Only necessary information is collected about you We only share your information with your consent Storage, retention and destruction of your personal information complies with existing legislation, and privacy protection protocols Our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario, and the law. Do not hesitate to discuss our policies with me or any member of our office staff. Please be assured that every staff person in our office is committed to ensuring that you receive the best quality dental care. How Our Office Collects, Uses and Disclosed Patients Personal Information Our office understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined here how our office is using and disclosing your information. This office will collect, use and disclose information about you for the following purposes: To deliver safe and efficient patient care To identify and to ensure continuous high quality service to assess your health needs To provide health care To advise you of treatment options To enable us to contact you To establish and maintain communication with you To offer and provide treatment, care and services in relationship to the oral and maxillofacial complex and dental care generally To communicate with other treating health care providers, including specialists and general dentists who are the referring dentists and/or peripheral dentists To allow us to maintain communication and contact with you to distribute health care information and to book and confirm appointments To allow us to efficiently follow up for treatment, care and billing For teaching and demonstrating purposes on an anonymous basis To complete and submit dental claims for third party adjudication and payment To comply with legal and regulatory requirements, including the delivery of patients charts and records to the Royal College of Dental Surgeons of Ontario in a timely fashion, when required, according to the provisions of the Regulated Health Professions Act Page 8 of 11

9 To comply with agreements/undertakings entered into voluntarily by the member with the Royal College of Dental Surgeons of Ontario, including the delivery and/or review of patients charts and records to the College in a timely fashion for regulatory and monitoring purposes. To permit potential purchaser, practice brokers or advisors to evaluate the dental practice To allow potential purchasers, practice brokers or advisors to conduct an audit in preparation for a practice sale PATIENT CONSENT FORM CON T To deliver your charts and records to the dentist s insurance carrier to enable the insurance company to assess liability and quantify damages, if any To prepare materials for the Health Professions Appeal and review Board (HPARB) To invoice for goods and services To process credit card payments To collect unpaid accounts To assist this office to comply with all regulatory requirements To comply generally with the law By signing the consent section of the Patient Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance. Your information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPS, and for the defence of a legal issue. Our office will not under any conditions supply your insurer with your confidential medical history. In the event this kind of a request is made, we will forward the information directly to you for review, and your specific consent. When unusual requests are received, will contact your for permission to release such information. We may also advise you if such a release is inappropriate. You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision, and the process. Patient Consent I have reviewed the above information that explains how our office will use my personal information, and the steps your office is taking to protect my information. I know that your office has a Privacy Code, and I can ask to see the Code at any time. I agree that Summer Hill/ Summerlyn Dental Care can collect, use and disclose personal information about as set out above in the information about the office s privacy policies. Patient Name. Relationship to the Patient: [ ] Self [ ] Parent [ ] Guardian Signature Print Name Page 9 of 11

10 Date (MM/DD/YYYY) Witness RELEASE OF RECORDS AND INFORMATION Smiles at Summer Hill Dental Care Summerlyn Dental Care Yonge St. Unit#2 459 Holland St W. Unit#3 Newmarket, Ont L3Y 0A3 Bradford, Ont L3Z 0C1 Phone (905) Phone (905) Fax (905) Fax (905) Dear Doctor: has recently enlisted our services. I understand that you may have recent records/radiographs, which may assist us. Please forward copies of the most recent x rays including panorex, perio charting and any other pertinent information including the following: Date of New Patient Examination: Date of last Recare Examination: Date of last Emergency Examination: Date of last Bite Wing X rays: Date of last Panorex X ray: I request that my files and personal information be transferred to Smiles at Summer Hill or Summerlyn Dental Care. I give my consent for the disclosure of my dental and health information Patient Signature (Parent or Guardian) Date (MM/DD/YYYY) Print Patient Name Patient s Date of Birth Page 10 of 11

11 Page 11 of 11