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Court Street Family Dentistry

76 COURT ST WESTFIELD, MA 01085,
WESTFIELD, MA 01085
4135687238

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
Dental History( * mandatory to fill )
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Do you feek twinges of pain when your teeth come in contact with

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Medical Health History( * mandatory to fill )

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

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

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Women

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  •  Penicillin
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  •  Penicillin or other antibiotics
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  •  Aspirin, Acetaminophen, or Ibuprofen
  •  Codeine, Demerol, or other narcotics
  •  Reaction to metals
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  •  Other
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Dental Financial Policy( * mandatory to fill )

The following is the financial policy for this office. A printed copy is available upon request.

Self-Pay patients are required to pay for all services by cash, check or credit card at the time services are rendered, unless specific arrangements have been made in advance. We also offer payment plan options for those that qualify.

 

Patients with a Dental Benefit Plan should note that MOST dental plans DO NOT cover 100% of the cost of treatment. Due to delays in processing claims and receiving payment from the dental plans, patients are required to pay the estimated patient responsibility and any deductibles that may apply at the time services are rendered. We attempt to estimate your dental plan reimbursement as closely as possible, but until we receive payment from your plan, this is just an ESTIMATE. We will assist you in making sure your dental plan claims are handled in a timely manner. Please be aware that outstanding balances on any claims that are not processed and/or paid in full within 45 days from the date of treatment will become the patient's responsibility.

*I understand that dental service fees are due at the time services are rendered and, if applicable, will be billed to my dental benefit plan on my behalf. I authorize my dental benefit plan to directly reimburse my provider, Dr. Marc Zive and Court Street Family Dentistry, for any services rendered.

 

*I understand that it is my responsibility to provide the dental office with accurate and current information about my identity, residential address, employer information and dental benefit plan. I also understand that it is my responsibility to know the policies of my dental benefit plan and that the staff at kClinicName is not responsible for knowing the specific policies of my dental benefit plan.

I understand that it is my responsibility to provide the dental office with accurate and current information about my identity, residential address, employer information and dental benefit plan. I also understand that it is my responsibility to know the policies of my dental benefit plan and that the staff at kClinicName is not responsible for knowing the specific policies of my dental benefit plan.

*I understand past due patient balances over 30 days are subject up to a $15 billing fee and/or finance charges of 1.5% per month (18% annual). I agree that if this account is not paid within 90 days, and kClinicName should retain an attorney or collection agency for collection, I agree to reimburse kClinicName the fees of any collection agency, which may be based on a percentage at a maximum of 35 % of the debt, and all costs, and expenses, including reasonably attorneys' fees, we incur in such collection efforts.

 

If you have any questions, feel free to ask at any time. We wish to be of assistance any way we can.

 

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CONSENT FOR GERENAL DENTAL PROCDURES( * mandatory to fill )

You, the patient, have the right to accept or reject dental treatment recommendations by Dr. Marc Zive 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 as discussed by Dr. Marc Zive or shown in the CAESY Education Video Segments.

 

Do not consent to treatment unless and until you discuss potential benefits, risks and complications with Dr. Marc Zive  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 our office with accurate information before, during and after treatment. It is equally important that you follow Dr. Marc Zive 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 Dr. Marc Zive advice, you may increase the chances of a poor outcome.

 

1. Treatment to be Provided

I understand that during my course of treatment the following care may be provided: Examinations, Preventive Services, Restorations, Crowns, Bridges, Cosmetic Dentistry and other General Dental procedures.

 

2. Drugs and Medications

I understand that antibiotics, analgesics, anesthetics, and other medications have the potential to cause allergic reactions including redness and swelling of tissues, pain, itching, vomiting and anaphylactic shock (severe allergic reaction).

 

3. Changes in Treatment Plan

 

I understand that during treatment it may be necessary to change, abort or add procedures due to conditions found while working on teeth that were not discovered during the examination. These may include root canal therapy, extraction or crown procedures. I give permission to Dr. Marc Zive to make any/all changes, additions and deletions to my treatment plan as necessary.

 

 

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CANCELLATION POLICY( * mandatory to fill )

As a new patient to Court Street Family Dentistry, we welcome you. As an existing patient, we thank you for your continued confidence in our office. We would like to take this opportunity to make you aware/remind you of our policy on schedule changes and cancellations.

Our office does not use the automated assignment of appointments. Appointment times at Court Street Family Dentistry, are exclusive for each patient. We do not intentionally overbook our schedule. Our staff will present you with an appointment card at the time of scheduling and you will receive advance reminders by email, text message and/or phone message. It is the patient's responsibility to ensure that our office has accurate and up-to-date contact information on file. Our office reminder system will ONLY ACCEPT CONFIRMATIONS. Our office will require a minimum of TWO FULL OFFICE OPERATING DAYS (Monday through Thursday, 9 AM to 4 PM) notice to cancel or reschedule an existing appointment.

To change or cancel an appointment, you will be required to speak directly with the receptionist during operating hours. Phone messages, texts, emails or a failure to respond to the automated confirmation request are not acceptable. Failure to comply with this policy will result in a minimum $50 'NO SHOW' fee assessment.

We are confident that this policy will help discourage schedule changes that may inconvenience other patients as well as our office staff.

 

I have read, understand and will abide by the Court Street Family Dentistry, Cancellation Policy.

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Consent for Local Anesthetic Injections( * mandatory to fill )

I,  the patient, hereby authorize Court Street Family Dentistry and members of its licensed staff to perform a local anesthetic injection(s).

I understand, and it has been explained to me, that there are some risks in the administration of local anesthetics. Most risks are related to the position of the nerves under the tissue at the site of the injection which cannot be determined prior to the administration of the anesthetic agent. Although the risks seldom occur they might include loss of or disturbed sensation of the tongue and lip on the side of the injection. If this occurs it is often temporary, and normal sensation usually returns in several days. However, in very rare cases the loss of sensation may extend for a longer period and may become permanent. In addition, injecting a foreign substance into the body such as an anesthetic agent may result in an allergic reaction. Allergic reactions to these agents are rare but may take place.

I further understand that individual reactions to treatment cannot be predicted and that if I experience any unanticipated reactions following the injection(s), I agree to report them to the office as soon as possible.

I have been told that the success of my dental treatment depends upon my cooperation in keeping scheduled appointments, following home care instruction, including oral hygiene and dietary instructions, taking prescribed medication and reporting to the office any change in my health status.

I acknowledge that no guarantees or assurances have been given by anyone as to the results that may be obtained.

 

I have discussed all of the above with the doctor, and have had all of my questions answered.

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(Your IP Address : IP:3.95.131.97 )
Dental Financial Policy( * mandatory to fill )

The following is the financial policy for this office. A printed copy is available upon request.

Self-Pay patients are required to pay for all services by cash, check or credit card at the time services are rendered, unless specific arrangements have been made in advance. We also offer payment plan options for those that qualify.

Patients with a Dental Benefits Plan should note that MOST dental plans DO NOT cover 100% of the cost of treatment. Due to delays in processing claims and receiving payment from the dental plans, patients are required to pay the estimated patient responsibility and any deductibles that may apply at the time services are rendered. We attempt to estimate your dental plan reimbursement as closely as possible, but until we receive payment from your plan, this is just an ESTIMATE. We will assist you in making sure your dental plan claims are handled in a timely manner. Please be aware that outstanding balances on any claims that are not processed and/or paid in full within 45 days from the date of treatment will become the patient's responsibility.

*I understand that dental service fees are due at the time services are rendered and, if applicable, will be billed to my dental benefit plan on my behalf. I authorize my dental benefit plan to directly reimburse my provider, Dr. Marc Zive and Court Street Family Dentistry for any services rendered.

*I understand that it is my responsibility to provide the dental office with accurate and current information about my identity, residential address, employer information, and dental benefits plan. I also understand that it is my responsibility to know the policies of my dental benefit plan and that the staff at Court Street Family Dentistry is not responsible for knowing the specific policies of my dental benefit plan.

*I understand past due patient balances over 30 days are subject up to a $15 billing fee and/or finance charges of 1.5% per month (18% annual). I agree that if this account is not paid within 90 days, and Court Street Family Dentistry should retain an attorney or collection agency for collection, I agree

to reimburse Court Street Family Dentistry the fees of any collection agency, which may be based on a percentage at a maximum of 35 % of the debt, and all costs, and expenses, including reasonable attorneys' fees, we incur in such collection efforts.

 

If you have any questions, feel free to ask at any time. We wish to be of assistance any way we can.

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NOTICE OF PRIVACY PRACTICES AND ACKNOWLEDGEMENT OF RECEIPT( * 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. 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 a 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 people 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 healthiest 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 OF RECEIPT OF NOTICE OF PRIVACY PRACTICE

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.

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HIPAA Information and Consent 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 the 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 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 a 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 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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