New Patient Packet

Form for registering new patients for both the offices.

Step 1 of 5

New Patient Form Packet

Childs Name (Patients Name)(Required)

First Last

Patients DOB(Required)

Gender

Parents Name(Required)

First Last

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

How did you hear about Us?(Required)

HIPAA

NOTICE PRIVACY OF YOUR HEALTH INFORMATION (HIPAA)

IT IS IMPORTANT THAT YOU KNOW HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. YOUR HEALTH INFORMATION PRIVACY IS IMPORTANT TO US.

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all health information that we maintain, including health information we created or received before we made the changes. You may request a copy of our notice at any time or print it online from our website.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Requirement by Law: We may use or disclose your health information when we are required to do so by law.

HIPAA- HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT

Signature

Financial Policy

FINANCIAL POLICY

Please read our financial policy below. We require you read and sign prior to any treatment.

FEES AND PAYMENT POLICIES

In an effort to make needed services more affordable, payment for professional services is due at the time dental treatment is provided. If you have insurance, then your estimated co-‐payment is due as service is rendered. If an account shows an overdue balance, future treatment may be delayed until balance is cleared. We accept checks, cash, Mastercard, Visa and American Express.

APPOINTMENTS We ask for your utmost courtesy regarding your scheduled appointments. Please allow 24 hours prior to the appointment time if you must cancel or reschedule. We understand that unforeseen business and personal emergencies do occur; however, repeated last minute cancellations and broken appointments will incur a charge of $50. Most insurance companies will not reimburse the cost of a missed appointment.

ABOUT INSURANCE

Fact 1 – No insurance pays 100% of all procedures.

Dental insurance is only meant to be an aid in receiving dental care. Many patients think that their insurance pays 100% of all dental fees. This is not true. Most plans only pay between 50-‐80% of the average total fee. Your employer has determined the amount of coverage according to the contract set up with the insurance company.

Fact 2 – Benefits are not determined by our office.

Insurance companies often state that the dentist’s fee has exceeded the usual, customary, or reasonable fee (UCR). This statement is very misleading and inaccurate.

The insurance company gathers data and arbitrarily chooses a level they call “allowable” UCR fee. The data is usually 3 to 5 years old, and the “allowable” fees are set by the insurance company so they can make a profit. Most dentists’ fees are higher than what the insurance company considers an average fee.

We are pleased to bill these insurance providers directly – as long as we have been supplied with all the necessary subscriber information. Without the necessary insurance information, we cannot submit claims to them, and will therefore require payment in full at the time of service. An estimated co-‐payment is requested at each appointment as service is rendered.

Please understand that we file dental insurance as a courtesy to our patients. We do not have a contract with your insurance company, only you do. We are not responsible for how your insurance company handles its claims or for what benefits they pay on a claim. We can only assist you in estimating your portion of fees for treatment. We at no time guarantee what your insurance will or will not do with each claim. We cannot be responsible for the accuracy of any insurance information. Your insurance company representative has provided this information to us. It is your responsibility to be familiar and understand your insurance policy and terms.

You are responsible for payment of any balance due not paid by your insurance company, including any unpaid deductible amounts or if your plan only allows one fluoride application per year, etc.

*THE PARENT WHO BRINGS THE PATIENT IN FOR TREATMENT IS RESPONSIBLE FOR ALL FEES INCURRED AT THE TIME OF SERVICES ARE RENDERED. WE CANNOT SEND STATEMENTS TO OTHERS/OTHER PARENTS.*

I have read the above conditions of treatment and payment and agree to their content