Merion Village Dental-Welcome Packet Form

Welcome Packet Form Welcome

Welcome!

Our doctors and staff would like to extend our personal greeting and warm welcome to Merion Village Dental. The trust and confidence that you are placing with us will be earned today and at subsequent visits.

Your satisfaction with your care is our top priority and we want you to have a pleasant experience. We pride ourselves on having the most professional and friendly staff. We are confident that, just like our other new patients, you will find this to be true.

We appreciate the opportunity to serve you and your family. Please let us know if you have any special requests!

Below you'll find our commitment to you, the newest member to our practice. We want you to know upfront what we expect of our patients AND what you can expect from us. Please take a moment to review and let us know if you have any questions.

Our Commitment:

We know that your time is valuable and we don't intend to waste it. Our commitment to you is to make certain that your appointment begins as punctually as possible.

Your Commitment:

It is very important that we receive notice of a change in plans at least 48 hours in advance of your reserved appointment time. Failure to provide adequate notice prevents us from otherwise scheduling a patient with a true dental need and can result in a $50 fee.

We will make several attempts to confirm your appointment via phone, email and text. If your appointment is unable to be confirmed within 24 hours of your reserved time, Merion Village Dental reserves the right to reschedule your appointment.

We remain on a strict schedule to ensure all of our busy patients are seen promptly. If you are more than 10 minutes late for your reserved time, we may not be able to complete your appointment in its entirety.

Sincerely,

The Doctors of Merion Village Dental

Welcome Packet Form Personal Information

Welcome to the MVD family!

Thank you for selecting our practice to fulfill your dental needs!

Merion Village Dental has earned the trust and respect of the Columbus community for over 40 years. We will continue to offer our patients the care they deserve because we respect both their dental needs and their time

First Name*

Last Name*

Middle Name

Preferred Name

Date Of Birth (dd/mm/yyyy)*

Street Address*

City*

State*

Zip*

Gender (insurance filing)*

Marital Status*

Social Security Number

Welcome Packet Form Contact Information

Email*

Home Phone Number

Cell Phone Number*

Work Phone Number

I would like to receive email updates, promotions & gifts from MVD

Welcome Packet Form Primary Dental Insurance (Medicaid, Medicare, Care Source, Molina, Community Health Plans Not Accepted at this time)

Primary Dental Insurance

Subscriber's name

Subscriber's social security #

Subscriber's date of birth

Employer

Plan number

Position

Welcome Packet Form Secondary Dental Insurance

Secondary dental insurance

Subscriber’s name

Subscriber’s social security #

Subscriber’s date of birth

Employer

Plan number

Position

Full time student

Yes
No

Welcome Packet Form Authorization

If under 18, parental guardian name

SIGNATURE (if under 18, parental guardian name and signature)*

(Please click below to draw/upload sign)

(Your IP Address :IP:3.239.242.55 )

$50/$50 Refer A Friend Program

We want to thank the person who referred you to our office. Even if you were not referred by a patient, we would still like to know how you heard about us!

How did you hear about us?*

We will need to gather some information about you in order to begin a new patient record. This information is strictly confidential and will be used for internal office use and insurance purposes only.

Welcome Packet Form Use and Disclosure of Health Information

SECTION A: PATIENT GIVING CONSENT

SECTION B: 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 to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: 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 of other important matters about your protected health information. A copy of our Notice 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. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person 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 to continue treating you if you revoke this Consent.

SIGNATURE

I,

, have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. 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 heath care operations.

SIGNATURE (Signature)*

(Please click below to draw/upload sign)

(Your IP Address :IP:3.239.242.55 )

If this Consent is signed by a personal representative on behalf of the patient, complete the following:

Personal Representative's Name

Relationship to Patient