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Patient Registration Form

High Desert Dental

12212 W AMITY RD,
Boise, ID, 83709
2083434732

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )

Patient or Parent Phone Numbers



  •  Text
  •  E-mail
  •  Phone Call
Emergency Contact Information( * mandatory to fill )
( * mandatory to fill )
Primary Dental Insurance( * mandatory to fill )
Secondary Dental Insurance( * mandatory to fill )
Referral Information( * mandatory to fill )


  •  Our Website
  •  Google
  •  Facebook
  •  Location
  •  Promotion
  •  Insurance Company
  •  Others
Consent for Services( * mandatory to fill )

As a condition of your treatment by this office, financial arrangements must be made in advance. This practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. All emergency dental services or any dental services performed without previous financial arrangements, or services not covered 100% by your dental insurance must be paid for at the time services are performed. Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patients account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. Not every service may be a covered benefit in all insurance plans or contracts and insurance companies may calculate their reimbursements in a manner that may not fully cover your charges. In the event this is the case, please contact your insurance company for an explanation. Please inform this office of any changes to your insurance coverage.

I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company. I also grant permission to you or your assignee, to telephone me to discuss matters related to this form and to confirm my dental appointments as necessary.


We require 24 hours notice if you need to change or cancel your appointment. Failure to do so may result in a charge for the broken appointment. There will be a $25.00 charge for all returned checks.

I have read the above conditions of treatment and payment and agree to their content.

 

 

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Patient Medical History( * mandatory to fill )
  •  Yes
  •  No

MEDICATIONS 

Note: If a larger list, give a paper copy to front desk.

  •  Yes
  •  No


  •  Pregnant
  •  Trying to get pregnant
  •  Nursing
  •  Taking oral contraceptives

Allergies

 Are you allergic to any of the following?



  •  Aspirin
  •  Acrylic
  •  Amoxicillin
  •  Codeine
  •  Metal
  •  Penicillin
  •  Local Anesthetics
  •  Latex
  •  Other

Do you currently have, or have you ever had, any of the following conditions?

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No


  •  2 times a Day
  •  Once a Day
  •  Weekly
  •  Seldom


  •  Soft
  •  Medium
  •  Hard
  •  Electric
  •  Sonicare
  •  Oral B


  •  1 time a day
  •  2 times a day
  •  2-4 times a week
  •  1-6 months times a month
  •  Seldom
  •  Never
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

To the best of my knowledge, all of the preceding information is true and correct. If I ever have a change in my health, I will inform the office at my next dental appointment without fail.

I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge.

I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.

 

I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.

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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 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 the 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 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, do 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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FINANCIAL POLICY( * mandatory to fill )

At High Desert Dental, our ultimate goal is your dental health and wellness. That's why we always present you with the best dental solutions possible to treat your personal situation. Each year we provide outstanding dental care to hundreds of patients. Some have dental insurance benefits but some do not. If you have dental benefits congratulations! You are extremely fortunate. Here are some important points you should know:

 Your dental benefits are based upon a contract made between you, your employer and your insurance. If you have any questions regarding your dental benefits please contact your employer or insurance company directly. Dental insurance plan pay for a percentage of your treatment needs and you are responsible for the remainder.

We currently accept a large number of PPO insurance plans. Although we can maintain computerized histories of payments by a given company, they do change; therefore it is impossible to give you a guaranteed quote at the time of service. We estimate your portion based on the most up-to-date information we have but it is ONLY AN ESTIMATE. If you would like exact out of pocket figures, we can submit a “pretreatment authorization” with your insurance company. Keep in mind this is not a guarantee of coverage and it may delay treatment.

 We will bill your insurance company as a courtesy. If insurance does not pay within 90 days, High Desert Dental reserves the right to request payment in full for services from you and let you collect the insurance funds due to you. This is rare, but it is important that you recognize that the insurance you have is a legal contract between YOU and your insurance company. Our office is not, and cannot be a part of that legal contract. Ultimately, you are responsible for all charges incurred in our office.

High Desert Dental does require payment in full for your portion at the time of service. We accept MasterCard, Visa, American Express, Discover, cash, and checks. If you are in need of payment plans, we also work with CareCredit which offers 6 or 12 months “same as cash" no interest financing. Our staff can assist you in the application process.

A specific amount of time is reserved especially for you and we strongly encourage all patients to keep their appointments. If you must change your appointment, we require at least 24 hours notice to avoid a $20 cancellation fee.

I have read and agree with the above conditions.

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Patient Record Release( * mandatory to fill )

I request that my dental records and x-rays are transferred to High Desert Dental via email if possible

Please email x-rays to drmatt@cableone.net

Please note the date x rays were taken for our records

 

Please Contact High Desert Dental at 208-343-4732 if you have any questions.

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Notice of Privacy Practices( * mandatory to fill )

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I HAVE CERTAIN RIGHTS TO PRIVACY REGARDING MY PROTECTED HEALTH INFORMATION. I UNDERSTAND THAT THIS INFORMATION CAN AND WILL BE USED TO:

 

* CONDUCT, PLAN AND DIRECT MY TREATMENT AND FOLLOWUP AMONG THE MULTIPLE HEALTHCARE PROVIDERS WHO MAY BE INVOLVED IN THAT TREATMENT DIRECTLY AND INDIRECTLY.

* OBTAIN PAYMENT FROM THIRD-PARTY PLAYERS

* CONDUCT NORMAL HEALTHCARE OPERATIONS SUCH AS QUALITY ASSESSMENTS AND PHYSICAIAN CERTIFICATIONS

I have been informed by you and your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices

High Desert Dental

12212 W. Amity Road

Boise, ID 83709

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my request for restrictions, but if you do agree then you are bound to abide by such restrictions.

 

 

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

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