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Patient Registration Form

Atwood Family Dental

2455 East 11th Street,
Odessa, TX 79761
(432) 337-6165

PATIENT INFORMATION( * mandatory to fill )
RESPONSIBLE PARTY'S INFORMATION( * mandatory to fill )
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  •  Cash
  •  Personal Check
  •  Credit Card
  •  Visa
  •  MasterCard
  •  I wish to discuss the offices payment policy.
INSURANCE INFORMATION( * mandatory to fill )
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ADDITIONAL INSURANCE ( * mandatory to fill )
MEDICAL HISTORY( * mandatory to fill )
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Do you have or have you had any of the following?

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( * mandatory to fill )

PATIENT DENTAL INFORMATION

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Have you ever experienced any of the problems in your jaw?

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AUTHORIZATION AND RELEASE

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf of my dependents.

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( * mandatory to fill )

APPOINTMENT SCHEDULING POLICY

We understand that unplanned issues can come up and you may need to reschedule an appointment. If that happens, we respectfully ask for scheduled appointments to be rescheduled at least 24 hours in advance. Our doctor and hygienists want to be available for your needs and the needs of all our patients. When a patient does not show up for a scheduled appointment, another patient loses the opportunity to be seen. Although we have always had a policy, circumstances have caused us to enforce a policy of charging for no-show appointments, and those appointments not canceled with at least a 24-hour notice. There will be a fee of $50.00 per appointment hour assessed if we do not receive a call 24 hours in advance to cancel or reschedule an appointment.

 

Thank you for being a valued patient and for your understanding and cooperation as we institute this policy. This policy will enable us to open otherwise unused appointments to better serve the needs of all our patients.

SMILE EVALUATION

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HIPAA FORM( * mandatory to fill )

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a "friendly" version. A more complete text is posted in the office.

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:

  1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient's condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff . You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.
  2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
  3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
  4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
  5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
  6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
  7. We agree to provide patients with access to their records in accordance with state and federal laws.
  8. We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.
  9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

 

I, 

on this date  

do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.

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FINANCIAL AGREEMENT( * mandatory to fill )

We are concerned about your dental health. We look forward to helping you with your dental care. Please remember that your dental insurance is your responsibility....but we can help. Regardless of what we might calculate as your dental benefit in dollars, we must stress the fact that you, the patient, are responsible for the total treatment fee. As a courtesy to you, we can accept assignment of benefit payments from most insurance companies. This will reduce your immediate, out-of-pocket expenditures. The ESTIMATE is based on limited information obtained from your insurance company. We allow 45 days for your insurance company to make a payment. After this time all inquiries (follow-up) n payments due become your responsibility.

 

I agree with the FINANCIAL RESPONSIBILITY for the total fee. The fees listed on this treatment plan will be honored for 90 days from the above date. After that time, the fees are subject to adjustments.

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