Patient Registration Form Patient Details

Patient Registration Form Contact Information

Patient Registration Form Responsible Party's Information

Patient Registration Form Emergency Contact Information

Patient Registration Form Primary Insurance Details

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Patient Registration Form Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. 

PLEASE REVIEW IT CAREFULLY.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY

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. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice. 

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. 

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

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. 

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters.) 


PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice.) 

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. 

Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). 

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request. 

Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail(e-mail), you are entitled to receive this Notice in written form. 

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, You may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. 

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. 

Acknowledgement : I, hereby acknowledge that I have read and fully understand the contents of this document, and I have been given the opportunity to ask any and all questions.
**You may refuse to sign this acknowledgement. 

Patient Registration Form HIPAA

THIS NOTICE DESCRIBES HOW HEALTH AND DENTAL CARE INFORMATION ABOUT YOU MAY BE DISCLOSED AND HOW YOU CAN GET ACCESS TO THS INFORMATION.

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996(HIPAA). I understand that by signing this consent, I authorize you to use and disclose my protected health information to carry out:

* Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)

* Medical Clearance

* Obtaining payment from third-party payers (EG. my insurance company or billing service)

* The day- to- day healthcare operations of your practice (EG: referral to our dental associates)

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more detailed description of the uses and disclosures of my protected health information and my rights under HIPAA.

I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at this time to obtain the most current copy of this notice.

We at Beautiful Smiles are committed to obeying all Federal State and local Laws and Privacy Practices. If any other uses or disclosures than the ones listed above are needed, the information will only be released with the written authorization of the individual in question. This written authorization may be revoked at any time by the individual.

 

I have read and understand the above Notice of Privacy Practices.

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I give Beautiful Smiles staff and Doctors permission to discuss my treatment and financial obligations with

Also this person can call on my behalf to request information, make appointments or act on my behalf as needed.

Patient Registration Form Financial Policy

Please read carefully and sign to acknowledge understanding and agreement

Thank you for choosing us as you dental care provider. We are committed to providing you with the best dental care available.

Available Payment Options.

You can choose from ~ Cash, Check, Visa, Mastercard, American Express

CareCredit payment plan option, ask us for detailed information.

Regarding Insurance.

  • For covered services, we ask that all co-pays and deductibles be paid on the day of treatment. Since your insurance company may not cover all costs, we ask that you pay any percentage of your balance not paid by your insurance on the day of treatment.
  • For services that are not covered by your insurance, we ask that you pay the entire fee the day of your treatment.
  • We will attempt to answer any questions we can about your insurance and, when possible We will assist in resolving complications with your insurance company. Please understand that We cannot Speak on their behalf. Your insurance contract is an agreement between you, your employer and your insurance carrier. In the event that your insurance company has not paid (on your behalf), you will be responsible to pay your account.

Patients Without Insurance.

  • For those patients without insurance coverage, you will be responsible for payment on the day of treatment. If you are not able to pay in full, or if your treatment requires several visits, you will be given an estimate and will be able to discuss payment arrangements with a member of our business office Staff.

Cancellation/No Show Policy.

  • Our office requires notice to cancel your appointment in the case of an emergency.
    We reserve the right to charge a fee, for those not giving notice.

Collections

  • A charge will be added to your account for any returned checks. You are responsible to pay all costs of collecting, or attempting to collect any debt owed on this account. This includes all attorneys fees, interest and late fees.

X-Rays.

  • You are responsible to pay a fee for duplicate copies of your X-rays.

 

I hereby authorize payment to

by the group insurance, otherwise payable to me.

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Patient Registration Form General Consent

consent to be a patient at the above-named office and agree to a radiographic and clinical examination. I also understand and agree to the following:

1. During the course of treatment, I may require procedures in all phases of dentistry including periodontics (gum treatment and surgery) fixed and removable prosthodontics (crowns, bridges, and dentures) restorative dentistry, fillings, temporomandibular disorder treatment, sleep apnea treatment, pediatric dentistry, and radiography.

2. I will provide a thorough and complete medical history, supply a full list of my medications with dosages, and consent to my dentist communicating with my other medical practitioners to inquire about any aspect of my health history. I will also notify the doctor at future appointments if my medical history changes.

3. No guarantees can be made about treatment outcomes, restoration longevity, or prognoses. I understand that any branch of medicine, including dentistry, can involve unanticipated results.

4. I will pay in full any cost of treatment or insurance copayments according to the office’s financial policy. I understand that even if my insurance pre-estimate is given or a procedure has been pre-approved, I am responsible for any costs that my insurance does not cover.

5. My treatment plan may change at any time and I will do my best to approach my dental care with optimism and open communication with my dentist, hygienist, and dental office staff.

6. I am welcome to ask questions about any aspects of my dental care and will request information if I am confused or need more information. I am responsible for clarifying any aspects of my treatment that I am unsure about.

7. Please be aware surveillance cameras are on premises throughout the office for your protection and ours.

 

OUR FINANCIAL POLICY

ALL ACCOUNTS ARE DUE AND PAYABLE AT TIME OF SERVICE. If a procedure requires multiple appointments, payment is required in full at the first appointment.

Payment options:
1. Cash, Care Credit, MasterCard, Visa, Discover, and American Express.

Patient with insurance: The PATIENT is responsible for the ESTIMATED non-covered portion, procedures and/or deductibles at the time of the service. If the insurance company does not pay after 60 days, we will bill you directly for the full balance.

Parents not accompanying their child to an appointment must make PRIOR arrangements for payment (cash, check or credit card authorization).

Parents accompanying their children are financially responsible for payment.

Records can be viewed at any time. There is a nominal charge of $35.00 for release or copies of records.

 

When time is lost due to last-minute appointment changes, other patients in need of treatment cannot be seen and treatment is delayed. With respect to unforeseen emergencies should any scheduling changes be required, we kindly request at least 24 hours advance notice. If recurring cancellations occur without the requested 24-hour notice, the patient will be charged a $50.00 fee per hour for a broken or canceled appointment.

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Patient Registration Form Allergy List

  •  Aspirin
  •  Pencillin
  •  Codeine
  •  Acrylic
  •  Metal
  •  Latex
  •  Sulfa Drugs

Patient Registration Form Medication List

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Patient Registration Form Medical History

Do you have, or have you had, any of the following?

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Do you have any disease, condition, or problem not listed previously that you feel we should know about? If so, please describe

During the past 12 months, have you taken any of the following?

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Women

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Patient Registration Form Dental Health History

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Do you feel twinges of pain when your teeth come in contact with:

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Patient Registration Form Photograph Release Form

I grant Beautiful Smiles the right to take photographs of me and my dental work. I authorize Beautiful Smiles to post any of these pictures on all social media sites. I also authorize Beautiful Smilesits assignees and tranferees to copyright, use and publish the same in print and or electronically.

I agree that Beautiful Smiles may use such photograph me and my dental work me and without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content.

I have read and understand the above: 

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Patient Registration Form Oral Cancer Screening

Complete each time the examination is performed and place in the patient's file. Our practice continually looks for advances to ensure that we are providing the optimum level of oral health care to our patients. We are concerned about oral cancer and look for it in every patient. One American dies every hour from oral cancer. Late detection of oral cancer is the primary cause that both the incidentals and mortality rates of oral cancer continue to increase. As with most cancers, age is the primary risk factor of oral cancer. Tobacco and alcohol use are other major predisposing risk factors but more than 25% of oral cancer victims have no such lifestyle risk factors. Oral cancer risk by

Patient profile is as follows: 
Increased risk: Patients ages 18-3
Sexually active patients (HPV 16-18)
High risk: Patients each 40 and older; tobacco users any age, any time within 10 years.
Highest risk: patients each 40 and older with lifestyle risk factors (tobacco and or alcohol use);
Previous history of oral cancer.

We have recently Incorporated ViziLite Plus in our oral screening standard of care. We find that ViziLite plus along with a standard oral cancer examination improve the ability to identify suspicious areas at their earliest stages. ViziLite Plus is similar to prove an early detection procedure for other cancers such as mammography, Pap smears, and PSA. 

ViziLite Plus is a simple and painless examination that gives the best chance to find any oral abnormalities at the earliest possible stage. Early detection of pre-cancerous tissue can minimize or eliminate the potentially disfiguring effects of oral cancer and possibly save your life. The ViziLite Plus exam will be offered to you annually.

This enhanced examination is recognized by American Dental of Florida Plantation cold revision committee as CDT 2007-2008 procedure code D0431 however this exam might not be covered by your insurance.

 

The fee for this enhanced examination is $45.00.

  •  YES: I authorize Beautiful Smiles to perform the ViziLite Plus exam along with the standard oral cancer examination. I accept full financial responsibility for this enhanced examination.
  •  NO: I would prefer not to have a ViziLite Plus exam at this time.
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