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PATIENT REGISTRATION

Ryan M.Clancy DMD PC

80 High Street,
Medford, MA 02155
(781) 396-8558

Patient Details( * mandatory to fill )

If you are completing this form for another person, what is your relationship to that person? 

Dental Information( * mandatory to fill )

Have you experienced any of the following

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Do you

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Have you ever had any of the following

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Responsible Party's Information( * mandatory to fill )
Medical Information( * mandatory to fill )
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Who are your doctors?

* Emergency Contact

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Are you allergic to or have you had a reaction to

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 Have you ever had any of the following

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Please indicate whether you have or had any of the the following diseases or conditions

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NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health Issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

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Electronic Payment Service( * mandatory to fill )

Cosmetic & Esthetic Dentistry (Ryan M Clancy DMD PC) requests all accounts to have a credit card on file for use as an electronic payment option. The electronic system we utilize allows us to securely store payment and billing options for each individual patient. This allows us to streamline our billing department and offer each patient a personalized and straightforward process of covering his or her dental expenses. Monthly payment plans can be set up through Care Credit. All of your dental, insurance, or financial information is stored in a state-of-the-art, highly secured, firewalled, and encrypted database. This database meets/exceeds all state and federal requirements to protect your valuable information.

 

Collections & Billing Policy

 

All co-payments, co-insurance, and deductibles are due at the time of service (These payments are eligible for a 10% Pre-payment savings, provided payment is made 1 week ahead of scheduled treatment). If a patient leaves the office without paying his/her co-payment, co-insurance, or deductible it will be immediately charges to the credit card or checking account on file. If this credit card is denied, Cosmetic & Esthetic Dentistry may apply a $35 fee to the account and the account may be sent to collections. In addition, these accounts will be subject to a 1.5% monthly service charge or a minimum of one dollar. In the event an account is sent to collections, you will be responsible for full payment of your account and all collection fees incurred, including attorney fees, court costs, etc.

 

I authorize Cosmetic & Esthetic Dentistry (Ryan M Clancy DMD PC) to charge outstanding patient balances to the following credit card.

  •  VISA
  •  MASTERCARD
  •  DISCOVER
  •  AMEX
  •  Care Credit

 

Please bring your credit card to the front desk when turning in these forms.

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FINANCIAL POLICY( * mandatory to fill )

Accepted Forms of Payment:        

We accept payment in the form of cash, check, debit, credit card (Visa, MasterCard, Discover, or America Express) and Care Credit. 

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Insufficient or Declined Transactions and Fee’s:

If a credit card is declined or a check is returned for insufficient funds, Cosmetic & Esthetic Dentistry will apply a fee to the account for $25 for any credit card transaction that is declined and $50 for any check that is returned insufficient funds. We will also apply a fee of $35 dollars if your account is sent to a collection’s agency.                      

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Missed or Cancelled Appointment Policy:

Your appointment is reserved specifically for you. A missed appointment greatly affects the practice due to the loss of revenue from an empty appointment. A missed appointment impacts the access of other patients to more timely care. We will make all efforts to reschedule any appointment to meet your needs if given at least 24-hour notice. We ask that our patients arrive on time for their designated appointment. Arriving more than 10 minutes past your scheduled appointment time will result in a failed appointment. Failure to show for hygiene appointment will result in a $58 fee. Failure to show for an appointment with one of the doctors will result in a $100 fee. No new appointments will be made unless your account balance is paid in full. Anyone who does not show for 3 appointments will be dismissed from the practice.

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Dental Services Policy:

All payments for any dental service will be paid for before or at the time of service. Services deemed to be billable to your dental insurance by Cosmetic & Esthetic Dentistry, will be submitted to dental insurance. Certain procedures require an advanced order of highly expensive materials, implant components, or may incur dental lab fees. These materials and fees are often unable to be returned and considered wasted. If your procedure requires that such an order be placed, a 50% payment will be collected at the time your appointment is scheduled. Failure to show for the appointment will result in the forfeiture of the down payment in order to compensate for the loss of the wasted products. Certain procedures requiring a long, reserved appointment will require a non refundable $200 deposit.

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Insurance Policy

The cost of your treatment is determined during the course of the examination. That cost may increase in the event the doctor determines that your specific situation requires a more in-depth examination or additional procedures. For patients with claims that will be billed directly to a dental insurance carrier: Know your insurance! You are ultimately responsible for payment. When authorizing Cosmetic & Esthetic Dentistry to bill a claim to your dental insurance on your behalf, payment will be made directly to us. Acceptance of assignment by our office does not absolve you of financial responsibility for services rendered. In the event your insurance carrier informs us that a service is not covered, partially covered, etc., you are responsible for the payment in full. We can make no guarantee of coverage or payment. You are responsible for all co-payments and deductibles before or at the time of your visit.

If you have concerns regarding your coverage, contact your insurance carrier directly. If you have an insurance carrier that we are not a contracted provider for, you are responsible for payment. Claims may be self-submitted for out-of-network benefits; however, we cannot determine your coverage or reimbursement rate. Contact your insurance carrier for out-of-network policy and coverage.

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I have read and understand the above policies

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GENERAL CONSENT( * mandatory to fill )

Informed Consent For General Dental Procedures

 

You, the patient, have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment. Do not consent to treatment unless and until you discuss potential benefits, risks, and complications with your dentist and all of your questions are answered. By consenting to the treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the probability of occurrence. It is very important that you provide your dentist with accurate information before, during, and after treatment. It is equally important that you follow your dentist's advice and recommendations regarding medication, pre and post treatment instructions, referrals to other dentists or specialists, and return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome. Please read and initial the items below and sign at the bottom of the form. 

1. Treatment to be Provided

I understand that  during my course of  treatment that the following care may be provided :

  •  Examinations
  •  Preventive Services
  •  Restorations
  •  Crowns
  •  Bridges
  •  Other
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2.Drugs and Medications

I understand that antibiotics, analgesics, and other medications can cause allergic reactions causing redness and swelling of tissues; pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction).

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3. Changes in Treatment Plan 

I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination, the most common being root canal therapy following routine restorative procedures. I give my permission to the dentist to make any/all changes and additions as necessary.

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4. I give permission to the dental office to bill my dental insurance provider for the treatment provided, if applicable.

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HIPPA NOTICE OF PRIVACY PRACTICES( * mandatory to fill )

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.

We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 06/25/2015, and will remain in effect until we replace it.

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 provide the new Notice at our practice location, and we will distribute it 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.

How We May Send Health Information About You

Your protected health information (PHI) includes information relating to your mental or physical health and to the health care provided to you, including materials like your dental records, dental x-rays, and payment records. Some documents containing PHI may include such sensitive personal information as a Social Security number, credit card number, mental health diagnosis, genetic information, alcohol/substance abuse records, positive HIV status, an other kinds of sensitive information. Sometimes our dental practice needs to send PHI to the patient or to someone else, such as a specialist. There are various ways to send PHI, including email and other electronic means. Our dental practice does not encrypt email or other electronic forms of communication. There is a risk that unencrypted information may be acquired by hackers or received by unintended recipients. If you are concerned about the security of PHI, that may be sent unencrypted, please let us know and we will send it a different way, which may include providing the information to you to deliver. 

How We May Use And Disclosures Health Information About You

We may use and disclose your health information for different purposes, including treatment, payment, and health care operations. For each of these categories, we have provided a description and an example. We may use and disclose your health information for different purposes, including treatment, payment, and health care operations. For each of these categories', we have provided a description and an example. Some information, such as HIV-related information, genetic information, alcohol and/or substance abuse records, and mental health records may be entitled to special confidentiality protections under applicable state or federal law. We will abide by these special protections as they pertain to applicable cases involving these types of records.

Treatment: We may use and disclose your health information for your treatment. For example, we may disclose your health information to a specialist providing treatment to you.

Payment: We may use and disclose your health information to obtain reimbursement for the treatment and services you feceive from us or another entity involved with your care. Payment activities include billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your dental health plan containing certain health information.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, conducting training programs, and licensing activities.

Individuals Involved In Your Care or Payment for Your Care: We may disclose your health information to your family or friends or any other individual identified by you when they are involved in your care or in the payment for your care. Additionally, we may disclose information about you to a patient representative. If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information.

Disaster Relief: We may use or disclose your health information to assist in disaster relief efforts.

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.

Public Health Activities: We may disclose your health information for public health activities, including disclosures to : prevent or control disease, injury or disability; report child abuse or neglect; report reactions to medications or problems with products or devices; notify a person of a recall, repair, or replacement of products or devices; notify a person who may have been exposed to a disease or conditions; or notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. 

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Law Enforcement: We may disclose your PHI for law enforcement purposes as permitted by HIPPA, as required by law, or in response to a subpoena or court order.

Health Oversight Activities: We may disclose you PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Judicial and Administrative Proceedings: If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose health information about you in response to subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about the request or to obtain an order protecting the information requested. Research: We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information.

Coroners, Medical Examiners, and Funeral Directors: We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties.

Fundraising: We may contact you to provide you with information about our sponsored activities, including fundraising programs, as permitted by applicable law. If you do not wish to receive such information from us, you may opt out of receiving such communications.

Other Uses And Disclosures Of PHI

Your authorization is required, with a few exceptions, for disclosure of psychotherapy notes, use or disclosure of PHI for marketing, and for the sale of PHI. We will also obtain your written authorization before using or disclosing your PHI for purposes other than those provided for in the Notice (or as otherwise permitted or required by law). You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization. 

Your Health Information Rights Access: You have the right to look at or get copies of your health information, with limited exceptions. You must make a request in writing. 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. If you request information that we maintain on paper, we may provide photocopies. If you request information that we maintain electronically, you have the right to an electronic copy. We will use the form and format you request if readily producible. We will charge you a reasonable cost-based fee for the cost of supplies and labor of copying, and for postage if you want copies mailed to you. Contact us using the information listed at the end of this Notice for an explanation of our fee structure. If you are denied a request for access, you have the right to have the denial reviewed in accordance with the requirements of applicable law.

Disclosure Accounting: With the exception of certain disclosures, you have the right to receive an accounting of disclosures of your health information in accordance with applicable laws and regulations. To request an accounting of disclosures of your health information, you must submit your request in writing to the Privacy Official. If you request this accounting more than once a 12 month period, we may charge you a reasonable, cost-based fee for responding to the additional requests.

Right to Request a Restriction: You have the right to request additional restrictions on our use or disclosure of your PHI by submitting a written request to the Privacy Official. Your written request must include what information you want to limit, whether you want to limit our use, disclosure or both, and to whom you want the limits to apply. We are not required to agree to your request except in the case where the disclosure is to a health plan for purposes of carrying out payment or health care operations, and the information pertains solely to a health care item or service for which you, or a person on your behalf, other than the health plan, has paid our practice in full.

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. Your must make your request in writing. Your request must specify the alternate means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. We will accommodate all reasonable requests. However, if we are unable to contact you using the ways or locations you have requested we may contact you using the information we have.

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. If we agree to your request, we will amend your record and notify you of such. If we deny your request for an amendment, we will provide you with a written explanation of why we denied it and explain your rights. 

Right to Notification of a Breach: You will receive notifications of breaches of your unsecured protected health information as required by law.

Electronic Notice: You may receive a paper copy of this notice upon request, even if you have agreed to receive this notice electronically on our Web site or by electronic mail (e-mail).

Questions and Complaints lf 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.

Contact Officer: Ryan Clancy, DMD, MAGD          Telephone: 781-396-8558 Fax: 781-396-8559

E-mail: rclancyPcosmeticsmileteam.com             Address: 80 High Street, Medford, MA 02155

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices 

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