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Age 18 Plus Patient Information Forms

Champlin Family Dental

11942 Business Park Blvd,
Champlin, MN 55316
(763) 323-0678

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
Patient Communication Form( * mandatory to fill )

Family and Friends. It is the office policy of this Practice not to release confidential medical and health information regarding your treatment to family members or friends, except for 1) parent/legal guardian; 2) other persons authorized by the patient; 3) as we may reasonably infer from the circumstances (for example, if you bring a family member or friend into the exam room, we will assume, unless you object, that the person is entitled to receive information regarding your treatment); 4) in emergency situations, or 5) as otherwise permitted by the Health Insurance Portability and Accountability Act (HIPAA).

If you anticipate that you will need or want your medical or health information to be provided to family members, friends, or caretakers/babysitters, please sign below so that we can release that information to that person. Please check make each box below for person(s) you authorize to share any personal health information with. By signing below, you authorize the following people to receive information regarding your treatment or care.

You have the right to update or make any changes to this form at anytime. If you do make changes to this form, you do understand that the practice may have already released information about you after you gave original permission. 

  •  Parents
  •  Siblings
  •  Friends
  •  Legal Guardians
  •  Spouse/significant other
  •  Children
  •  Grandparent
  •  Distant Family
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OFFICE POLICIES AND FINANCIAL AGREEMENT( * mandatory to fill )

We are committed to providing you with the highest quality dental care. The following is a statement of Champlin Family Dentals Office/Financial Policies. We ask that you please read, agree to, and sign before any treatment is rendered.

IF YOU HAVE INSURANCE
Our goal is to maximize your Insurance benefits. It is important to understand that Dental insurance is a contract between you, the insured, and your insurance company. Dental Insurance was not designed to pay for all dental care. The treatment recommended by Champlin Family Dental Doctors is never based on what your insurance company will pay. Due to pending claims and patient privacy issues, we do not always know how much an insurance company has already paid to another office or specialist, and the balance remaining on a yearly maximum.

Please be prepared to show your insurance card and driver's license at the time of your visit. It is the patient's responsibility to understand the extent and limits of your coverage and to provide our staff with accurate information so as a curtsey to you, we can process your claim efficiently (i.e. insurance company address, phone number, etc.). It is not our place to enter into disputes between you and your insurance company regarding deductibles, copayments, coverage, etc, Other than to provide factual information. We do not directly participate in every Insurance program. At the time of treatment, the patient/guarantor is responsible for the estimated portion the insurance does not cover or the down payment arrangements discussed at the time of presenting your treatment plan. If for some unforeseen reason your insurance carrier has denied or not made payment within 60 days, the patient guarantor is responsible for the balance in full. Certain conditions may require your authorization for release of X-rays and or narratives for assignment of benefits. Your signature below authorizes us to offer this when it applies to your situation. If we do not participate with your insurance, 100% of the total cost is requested at the time of service, Our staff will help you process whatever paperwork is required. However, the ultimate responsibility lies with you for payment of any and all monies due.

RELEASE AND ASSIGNMENT OF BENEFITS
I hereby authorize Champlin Family Dental to release to my benefits program or its representatives any information including the diagnosis and the records of any treatment or examination rendered to me. I authorize, if applicable, payment to be sent to Champlin Family Dental.

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PAYMENT OPTIONS
Cash, Check, Master Card, Discover, Visa or American Express. With prior approval, we are pleased to offer a choice of No Interest or Extended Payment Plans to qualified applicants through Care Credit. If you would like to make extended payments for services provided at our office, please ask any of our administrative teams for assistance in filling out an application form.

ADDITIONAL CHARGES
Interest will be added to any account with an outstanding balance over 60 days past due at a rate of 21% APR, or a flat rate of$5.00 a month whichever is greater.

If an account is turned over to collections a charge of$50.00 will be added to the account to cover the cost involved.

CANCELLATION POLICY

If you are unable to keep an appointment, we ask that you kindly provide us with a minimum of two business days' notice. Our office does not accept cancellation or changes in appointments after hours or by voice mail, you must call during our normal business hours. This courtesy on your part will make it possible to give your appointment to another patient who needs to see the dentist or hygienist

OFFICE HOURS
Monday Friday 7:30am-3:00pm

I have read, understand and agree to the above Office Policies and Financial Agreements

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HIPAA( * mandatory to fill )

TO THE PATIENT - PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

Purpose of consent: By signing this form, you will consent to our use and disclosure of your protected health information 10 carry out our treatment, payment activities, and healthcare operations.

Notice of Privacy Practice: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we may make of your protected health information, and other important matters about your protected health information. A copy of our Notice of Privacy Practices accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.
we reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices which will contain the changes. These changes may apply to any of your protected health information that we maintain.
You may obtain another copy of our Notice of Privacy Practices, including revisions, at any time by contacting:
Privacy Officer
Telephone: 763-323-0678
12233 Champlin Drive
Champlin, Minnesota 55316

consent Does Not Expire after one Year. By signing this consent form, I am explicitly giving informed consent for the release of health records and health information for the purposes listed herein and that this consent does not expire after one year for 1) the release of health records to a provider who is being advised or consulted with in connection w.ith the releasing provider's current treatment of myself; or, 2) the release of health records to an accident and health insurer, health service plan corporation, health maintenance organization, or third-party administrator for purpose of payment of claims, fraud investigation, or quality of care review and studies.

Right to Revoke: You have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the Privacy Officer listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation and that we may decline to treat you or continue treating you if you revoke this Consent. You may obtain a revocation of consent form upon request.

SIGNATURE
I have received a copy of this practice's Notice of Privacy Practices and have had the full opportunity to read and consider the contents of this Consent form. I understand that by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and health care operations.

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This form must be signed at the office

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT

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