Patient Registration Form Patient Details

Patient Registration Form Contact Information

Patient Registration Form

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Patient Registration Form Medical History

Have you ever had any of the following? (check boxes that apply):

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Patient Registration Form Financial and Privacy Policy

Decatur Smiles Financial & Privacy Policy

Thank you for choosing us as your dental care provider.

In an effort to keep dental costs down, while maintaining a high level of professional care, we have established this financial policy for your benefit. In order to operate our office as efficiently as possible, we will schedule each appointment with your specific needs in mind. Therefore, if you are more than fifteen minutes late, we may have to reschedule your appointment. If you are unable to keep your scheduled appointment: We require a 48-business hour cancellation notice to avoid a broken appointment fee of $75.00. We will make every effort to provide a courtesy reminder by text and/or phone call.

Payment is expected in full at the time of service, and for your ease and convenience, we offer the following types of payment arrangements.

We accept all major credit/debit cards for payment. Please be advised that all credit/debit transactions will assess a non-refundable payment fee of 3.5% of the transaction amount ($2.95 minimum fee) to cover the cost of processing fees.

We do accept cash and checks as forms of payment.

Two Equal Payments: For major multi appointment treatment. One-half is due at the beginning of treatment and the balance is due at next appointment.

Care Credit is available at 0% interest with 6 to 12 months to pay for your treatment. You may apply atcarecredit.com. Care Credit is a credit card. If you use this form of payment it does not absolve you from your fee for service responsibility to the practice.

All returned checks will incur a $45.00 fee for processing. Account balances over 90 days are subject to collections.

In the event that your payment is not cleared or returned back, your fees are due immediately in order to not receive theft of services charge.

DENTAL INSURANCE

IT IS YOUR RESPONSIBILITY TO KNOW YOUR INSURANCE BENEFITS.

By definition, dental insurance is a contract between the contracted individual and the insurance carrier. All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and your insurance company. Our office is not a party to that contract Therefore, all patients are responsible for all dental fees regardless of insurance company. Our doctor cares for her patients not based on insurance but on overall dental health, preventive and restorative needs. We do provide an additional service for patients by submitting their claims free of charge directly to their carrier under the following guidelines:

If insurance payment is paid directly to our office the patient is required to pay any copayments at the time of service. The co-payments are always an estimate. Insurance never guarantees payment to the provider. Please remember you are fully responsible for all fees charged by this office regardless of your insurance coverage.

COLLECTIONS

A monthly service charge at a fixed rate of 1.5% per month/18% per annum* of the unpaid balance as of the last day of each month will be assessed and added to the balance on all accounts exceeding sixty (60) days from the date of service unless previously written financial arrangements are made.

In the event my account becomes delinquent, I agree to pay the remaining balance plus the sum of the collection fee charged by the collection agency to whom a delinquent account is assigned for collection, in addition to reasonable attorney fees and court costs where such legal services are necessary.

I authorize the release of financially identifiable information concerning my account, including charges billed, payments made, and interest charges assessed, etc. to the dentist’s collection agency or collection attorney should collection procedures as described become necessary. I grant my permission to you or your assignee to telephone me at home or at my workplace to discuss matters related to this form. I also agree to let this office leave messages concerning appointments and/or results on my answering machine or with a family member.

This agreement supersedes all prior agreements signed, including any and all mediation or mediation/arbitration agreements. I acknowledge that any prior mediation or mediation/arbitration agreements signed previously related to financial arrangements or quality of care are null and void.

I authorize the dentist or her designees to release financially identifiable information and treatment descriptions and information, either electronically, by facsimile or in paper form to my insurance carrier, another oral health provider/specialist or any related entities that require such information to be submitted.

ASSIGNMENT OF BENEFITS

I authorize payment of my dental benefits to be made directly to Decatur Smiles.

PRIVACY POLICY

I have had the opportunity to review the Notice of Privacy Practices policy: (Laminated form on clipboard)

  •  PLEASE INITIAL

I understand and agree to the office policies explained above.

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Patient Registration Form HIPAA Form

AUTHORIZATION FORM FOR OTHER USES OF PROTECTED HEALTH INFORMATION

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information (PHI)about you pursuant to our general Patient Consent Form. On occasion, the patient and the Practice may want to use PHI for reasons other than treatment, payment and health care operations. This form summarizes the anticipated use of information about you for which this authorization is required. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Please list individuals who may receive and use the disclosed information:

The individuals who may use or disclose this information are Dr. Dillon and employees.

**Please specify what type of information you wish to disclose to the above individuals.

  •  ALL INFORMATION
  •  Appointment information ( ) x-rays
  •  Financial information ( ) medical records
  •  Personal identifying information ( ) insurance information
  •  Other information
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