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REGISTRO DE PACIENTES

Dental Garden

8710 Grand Mission Blvd. Suite A,,
Richmond, TX 77407
2818539215

INFORMACION DEL PACIENTE( * mandatory to fill )

Si el paciente es menor de edad PROVEER

  •  Mama
  •  Papa
  •  Los Dos
  •  Otro
PACIENTE DE CONTACTO DE EMERGENCIA( * mandatory to fill )
LO MAS GRANDE QUE NUESTRO PACIENTES LOS PUEDA DAR LA REFERENCIA A SU FAMILIA Y AMIGOS( * mandatory to fill )
  •  Si
  •  No
  •  Signo De Edificio
  •  Correo/anuncio
  •  Dental Garden Sitio Web
  •  Compania De Seguros
  •  Paginas Amarillas
  •  Si Tiene Seguro Por Favor
SI TIENE SEGURO POR FAVOR LO PUEDE PROPORCIONAR( * mandatory to fill )

PRIMARIO PORTADOR

PORTADOR SECUNDARIO

RECONOCER Y CONSENTIR

1. Por la presente autorizar medico o desgnado el personal para tomar rayos x, modelos de estudios, fotografias y otras ayudas diagonistas considerado apropiado por el medico para hacer un diagnostic a fondo de me, o las necesidades dentales de me dependientes.

2. Doy mi consentimiento para el uso y divulcacion del personal desginado por el medico de cualquier expediente de salud oral, escrito o electronico que sea individualmente identificable como el mio, o el de me dependiente, con el proposito de llevar a cabo mi tratamiento el pago, y el cuidado medico. Entiendo que solo se utilizer o divulgara la cantidad minima de informacion necesaria para proporcionar atencion de me informacion personal de salud esta completamente disponible.

3. Por la presente autorizo y pago directo de los beneficios del seguro dental de otra menera pagaderos a mi por los sevicios prestados, y directamente al Dental Garden. En el caso de que la compania de seguros me desdirija el pago, entiendo que soy responsible de remitir inmediatamente tales pagos al Dental Garden.

4. Acepto ser resposnable del pago de todos los servicios prestados en me nombre o en mis dependientes. Entiendo que el pago se vence en el momento del servicio a o que se hayan hecho otros arreglos.En el evento los pagos no son recibidos por fechas acordadas, entiendo que ya sea un 1 1⁄2% de retraso (18%APR) o un cargo por retraso de $15 por pago tardio pueden ser agredados a mi cuenta. Tambien estoy de acuerdo en informar al Dental Garden de cualquier cambio de direccion o numero de telefono dentro de 30 dias de dicho cambio. En caso de que no lo haga, authorize a Dental Garden a usar todos los medios debidos, incluyendo el uso de registros de historial crediticio, para determiner mi nueva direccion para propositos de facturacion.

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HISTORIA DENTAL( * mandatory to fill )

Bienvendos! Para que podamos propocionarle el major cuidado posible, por favor complete los dos lados de este formulario de historia clinica y dental. Toda la informacion es completamente confidencial.

  •  Yes
  •  No
  •  Yes
  •  No

Alguno de sus dientes esta sensible..?

  •  Si
  •  No
  •  Si
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

Si usted...?

  •  Si
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No

Ha tenido...?

  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Yes
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No

Si pudieras cambiarte los dientes?

  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
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  •  Si
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  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
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HISTORIAL MEDICO( * mandatory to fill )

Ha tenido las siguentes enfermedades o problemas?

  •  Si
  •  No
  •  Si
  •  No

LAS SIGUIENTES PREGUNTAS SON PARA SUS BENEFICIOS Y ASEGURAN QUE EL TRATAMIENTO TENDRA EN CUENTA SU ESTADO DE SALUD PASADO Y PRESENTE. ALGUNAS PREGUNTAS PUEDEN PARECER NO RELACIONADAS CON SU CONDICION DENTAL, PERO TODAS ESTAN ASOCIADAS CON LA ATENCION DE SALUD BUCAL APROPIADA. POR FAVOR, RESPONDA A CADA PREGUNTA.

  •  Si
  •  No
  •  Si
  •  No
  •  Yes
  •  No
  •  Si
  •  No
  •  Penicilina
  •  Tetracycline
  •  Sulfa Drugs
  •  Aspirina
  •  Codeina
  •  Otro.
  •  Si
  •  No
  •  Fen-Phen
  •  Pondimen
  •  Redux
  •  Otro
  •  Si
  •  No
  •  Si
  •  No

Indique cual de los siguientes ha tenido o tiene en la acutalidad. Circulo si o no a uno de ellos

  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
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  •  Si
  •  No
  •  Si
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  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
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  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
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  •  Si
  •  No
  •  Si
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  •  Si
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  •  Si
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  •  Si
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  •  Si
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  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  SI
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  SI
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No
  •  Si
  •  No

He respondido todas las preguntas al maximo de mi conocimiento.Si se necesita mas informacion, usted tiene me permiso para preguntarle al proveedor o agencia de salud respective, que puede divulgarle dicha informacion. Le notificare al medico cualquier cambio en mi salud o medicacion.

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DENTAL GARDEN PLLC 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.

THE PRIVACY OF YOUR PROTECTED HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your protected health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This notice takes effect September 23, 2013, 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 protected health information that we maintain, including protected 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 PROTECTED HEALTH INFORMATION

We use and disclose protected health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use and disclose your protected health information to a dentist, hygienist or other healthcare provider for treatment purposes.

Payment: We may use and disclose your protected health information to bill for and collect payment for services we provide to you.

Healthcare Operations: We may use and disclose your protected health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare providers, evaluating provider performance, conducting training programs, peer review, accreditation, certification, licensing or credentialing activities.

Authorization: In addition to our use and disclosure of your protected health information for treatment, payment or healthcare operations, you may give us written authorization to use your protected health information or to disclose it to anyone for any purpose. You may revoke such authorization at any time by written request, but we cannot take back any uses or disclosures already made with your permission. Unless you give us a written authorization, we cannot use or disclose your protected health information for any reason except those described in this Notice.

To Your Family and Friends: We may disclose protected health information about you to your family members or friends if we obtain your verbal authorization to do so or if we give you an opportunity to object and you do not object. We also may disclose protected health information to your family or friends if we can infer from the circumstances, based on our reasonable judgment, that you would not object, for example when you bring your spouse with you when treatment is discussed. We may use our professional judgment to infer that it is in your best interest to allow another person to pick-up filled prescriptions, medical supplies, x-rays or recommend that they take you to your physician or emergency room.

We may use or disclose protected 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, or your general condition. If you are present, then prior to use or disclosure of your protected 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 protected health information based on a determination using our professional judgment, disclosing only protected health information that is directly relevant to the person’s involvement in your healthcare.

Marketing Health-Related Services: We may use or disclose your protected health information for marketing purposes with your written authorization.

Required by Law: We may use or disclose your protected health information when we are required to do so by federal, state or local law or legal process, for example, subpoena, court order, administrative order, warrant, or summons; and pursuant to workers’ compensation laws.

Abuse or Neglect: We may disclose your protected 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 protected health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

Governmental Officials and Law Enforcement: We may disclose to authorized governmental officials protected health information required for lawful investigation, military authorities, the protected health information of Armed Forces personnel, and a correctional institution or law enforcement officials having lawful custody of protected health information of an inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as postcards, voicemail message, or letters) or information about oral health care, and related benefits and services.

PATIENT RIGHTS

Access: You have the right to look at or get copies of your protected health information, with limited exceptions. You must request access by sending us a letter to the address at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies, postage and staff time. If you request an alternative format that we can practicably provide, we will charge a cost-based fee for providing your protected health information in that format. If you prefer, we will prepare a summary or an explanation of your protected health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fees.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your protected 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.

Restriction: You have the right to request in writing that we place additional restrictions on our use or disclosure of your protected 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). We are required to agree to requests that we not disclose protected health information to your health plan with respect to services for which you have paid out of pocket in full.

Alternative Communication: You have the right to request that we communicate with you about your protected 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 protected 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.

Breach Notification: You have the right to receive notice if the security of your unsecured protected health information is breached.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive a paper copy of this Notice upon request.

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 protected health information or in response to a request you made to amend or restrict the use or disclosure of your protected health information or to have us communicate with you by alternative means or at alternative locations, you may submit a complaint 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 protected health information. You will not be penalized in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Patient Rights  Information:

Dental Garden PLLC

8710 Grand Mission Blvd

Suite A

Richmond, TX 77407

(281) 853-9215

Complaints:

Dental Garden PLLC

8710 Grand Mission Blvd

Suite A

Richmond, TX 77407

(281) 853-9215

ACUSO DE RECIBO DE AVISO DE PRACITCAS DE PRIVACIDAD( * mandatory to fill )

* usted puede negarse a firmar este reconocimento *

Yo

Ha recibido una copia del aviso de practica de privacidad de esta oficina.

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Formulario de asignacion de beneficios

Responsabilidad financiera

Todos los servicios profesionales prestados se cargan al paciente y se vencen en el momento del servicio, a menos que se hayan hecho otros arreglos previos con nuestra oficina de negocios. Los formuarios necesarios se completartan para presenter los pago de la compania.

Asignacion de beneficios

Por la presente asigno todos los beneficios dentales, para incluir los principals benefecios medicos a los que tengo derecho. Por el presente autorizo y mi compania de seguros, incluyendo Medicare,Medicaid, seguro privado, y cualquier otro plan de salud/medico, para emitir cheque(s) de pago directamente a Dental Garden para servicios dentales prestados a mi mismo Y/o a mis dependientes independientemente de mis beneficios de seguro, si los hubiere. Entiendo que soy responsible de cualquier monto no cubierto por el seguro.

Authorizacion para Divulgar la informacion medica

Por la presente autorizo a Dental Garden : (1) Divulgar cualquier informacion necesaria a las companies de seguros con respecto a mi enfermedad y tratamientos (2) Tramitacion de reclamciones de seguros generadas en el curso de examen o tratamiento; y (3) Permitir que una fotocopia de mi firma sea utilizada para procesar reclamos de seguro per el period de vida. Esta orden permenecera en vigencia hasta que yo sea revocada por escrito.

He solicitado servicios medicos de Dental Garden en nombre de mi y/o mis dependientes, y entiendo que al hacer esta solictued, me hago totalmente responsible financieramente de cualquier y todos los cargos incurridos en el curso del tratamiento autrizado.

Entiendo ademas que los honorarios son vencidos y pagaderos en la fecha en que los servicios son prestados y acuerdan pagar todos los cargos incurridos en su totalidad inmediatamente despues de la presentacion de la declaracion apropiada. Una fotocopia de esta cession se considerara valida como el original.

POLITICA DE CANCELACION DE CITAS( * mandatory to fill )

Nos esforzamos para rendir cuidad dental excelente a usted y al resto de nuestdros pacientes. En un intento de ser coherente con esto, tenemos una politica de cancelacion de cita que nos permite progammar citas para todos los pacientes. Cuando una cita esta progamada, ese tiempo se ha reservado para usted y cuando se pierde, ese tiempo no se puede utilizer para tratar a otro paciente

Nuestra politica de oficina es la siguiente:

Requerimos que usted le de a nuestra oficina un aviso de 48 horas en case de que necesite reprogramar su cita. Esto permite que ostros pacientes sean progammados en esa cita. Si usted pierde una cita sin contactar a nuestra oficina dentro del tiempo requerido, esto es considerado una cita perdida. Se le cobrara una tarifa de $59; esta cuota no puede ser facturada a su compania de seguros y sera su responsabilidad directa. No se pueden progammar citas futuras ni se pueden transferir registros sin el pago de esta cuota.

Ademas, si un paciente es mas de 20 minutos tarde sin previo aviso para una cita programada, consideraremos esto una cita perdida y la tarifa de cancelacion de $59 sera cargada.

Si tiene alguna pregunta con respect a esta poliza, por favor deje que nuestro personal lo sepa y estaremos encantados de aclararle cualquier pregunta que tenga.

Le agradecemos su patrocinio.

He leido y entiendo la politica de cancelacion de cita de la practica y estoy de acuerdo en estar obligado por sus terminus. Tambien entiendo y estoy de acuerdo en que tales terminus pueden ser enmendados de vez en cuando por la practica.

Yo,

(nombre), Ha recibido una copia de la politica de cancelacion de nombramiento Dental Garden.

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