Patient Forms

Patient Name:

Phone:

Address:

Responsible Party Information:

Patient Name:

Address:

Phone:

Primary Dental Insurance

These only need to be filled out if the insurance subscriber is other than patient, or if patient is under 18.

Name of Insured:

Insurance Authorization:

Consent for Services and Financial Policy

As a condition treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their Financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or ay dental services performed without financial arrangements, must be paid for in cash at the time services are performed unless the arrangements are made.

Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for the payment of all dental services. This office will help prepare the patient's insurance forms or assist in making collection from insurance companies and will credit any collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

A service charge of 1.5 % per month (18% per annum) on the unpaid balance will be charge on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.

I understand that any fee estimate for this dental care can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of the treatment, or within five (5) days of billing if credit is extended. I further agree that the charges for services shall be billed unless objected to, by me, in writing, within the time payment is due. I further agree that a waver of any breach of any time condition hereunder shat not constitute waiver of any further term of condition and I further agree to pay all the cost and reasonable attorney fees if suit be instituted hereunder.

I grant my permission to you and your assignee, to telephone me to discuss this statement or my treatment.

HIPAA Acknowledgement

I understand that I may inspect or copy the health information by this authorization.

I understand that any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although revocation will not be effective as to the disclosure of records whose release I have previously authorized, or when the action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form.

I understand that information used or disclosed, pursuant to this authorization, could be subject ti re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality.

Request/Refusal for Interpretive Services

Appointment Cancellation Policy

We schedule time especially for you, without advance notice, we cannot reschedule other patients to fill your appointed time. If you miss an appointment without giving a 24-hour notice, you will be charged a $25 cancellation fee. For specially cancellation a $100 fee may be charged without a 48-hour notice.

Consent for Internet Communications

I grant my permission to the dental practice to upload and store confidential information (including account, appointment information and clinical information) to the secure web site for dental practice. I understand that, for my security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me; I understand the dental practice is not liable for any charges, damage, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice web site with my ID and password. I also agree to immediately notify the dental practice of any unauthorizes used of my ID or of any other need to deactivate my ID due to security concerns.

I also understand that State and Federal laws, as well as ethical and licensure requirement impose obligations with respect to patient confidentiality that limit ability to make use of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms f this Agreement and thereafter, comply with laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload, and use my information in connection with the operation or such services and is acting on my behalf in uploading patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the web site on my behalf. I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITOR, STORED, UPLOADED OR RECEIVED USING SITE OR THE SERVICES.

GENERAL QUESTION

Do you have or did you ever have any of the following?

Cardiovascular Health

Respiratory Health

Endocrine/Blood/Immune Health

Social

I hereby certify that I have read the foregoing and filled out this questionaire completely, I have advised you of all medical problems of which I am aware, I further certify that I, the unsigned, consent to the performing of x-rays and examination.

UPDATE

PREGUNTAS DE SALUD

Tiene usted o tenia alguna vez alguno de los siguentes?

Salud cardiovasculer

Salud repiratoria

Sistema endocrino

Social

Por medio de la presente certifico que he leido y completado el cuestionario de salud en su totalidad. He estipulado todos los problemas medicos de los que tenga conocimiento. El suscrito certifica y da su connontamiento para que que te lomon radiografias y so le examine.

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