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Patient Registration Form

Lakeview Dental

2291 S. Fort Apache Rd. #104,
Las Vegas, NV 89117
(702) 869-0001

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
Primary Insurance Details( * mandatory to fill )
  •  Yes
  •  No
Secondary Insurance ( * mandatory to fill )
  •  Yes
  •  No

Assignment & Release 

I certify that I, and/or my dependents, have insurance coverage with kPatientName & assign directly to kDentistName all insurance benefits if any, otherwise payable to me for services rendered. I understand that I am charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions, the doctor may use my health care information and may disclose information to the above-named insurance company and their agents for the purpose of obtaining payment or services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plans is completed or one year from the date signed below.

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Health History( * mandatory to fill )
  •  Anemia
  •  Arthritis,Rheumatism
  •  Artifical Heart Valves
  •  Artifical Joints
  •  Asthma
  •  Back Problems
  •  Blood Disease
  •  Cancer
  •  Chemical dependency
  •  Chemotherapy
  •  Circulatory Problems
  •  Cortisone Treatments
  •  Cough,persistent
  •  Cough Up Blood
  •  Diabetes -Type
  •  Epilepsy
  •  Fainting
  •  Glaucoma
  •  Headaches
  •  Heart Murmur
  •  Heart Problems
  •  Hemophilia
  •  Hepatitis
  •  High Blood pressure
  •  HIV/AIDS
  •  Jaw Pain
  •  Kidney Disease
  •  Liver Disease
  •  Mitral valve Prolapse
  •  Pacemaker
  •  Radiation Treatment
  •  Respiratory Disease
  •  Rheumatic Fever
  •  Scarlet fever
  •  Shortness of breath
  •  Skin rash
  •  Stroke
  •  Swelling of feet or ankles
  •  Thyroid problems
  •  Tobacco habit
  •  Tonsillits
  •  Tuberculosis
  •  Ulcer
  •  Venereal Disease
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

PHARMACY

  •  Bad breath
  •  Bleeding gums
  •  Clicking / popping jaw
  •  Food collection between teeth
  •  grinding teeth
  •  Loose teeth / Broken Fillings
  •  Periodontal treatment
  •  Sensitive to hot/ cold
  •  Sensitive to sweets
  •  Sores /Growth in your mouth
  •  Sensitivity when biting

The above information is accurate and complete to the best of my knowledge. I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.

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Medication List( * mandatory to fill )
Allergy List( * mandatory to fill )
  •  Aspirin
  •  Barbiturates (sleeping pills)
  •  Codine
  •  Local Anesthetic
  •  Penicillin/Amoxicillin
  •  Sulfa
  •  Latex
Oral cancer screening( * mandatory to fill )

We are very concerned about oral cancer, and conduct screening examinations on every patient.

The incidence of oral cancer continues to rise in the USA. The American Cancer Society indicates that in 2017, they except a remarkable 11% increase in this deadly disease. Alarmingly, 25% of the new oral cancer cases are people that do not have any of the traditional lifestyle risk factors, such as age, tobacco, and alcohol use.

Traditionally, dentists and hygienists have done oral cancer screening with the naked eye, but recently a new technology, the VELscope has received FDA approval. The VELscope(for Visually Enhanced Lesion scope) will help us pinpoint and identify suspicious tissue at earlier stages before they may become life-threatening concerns.

The VELscope testing is an addition to our traditional visual oral cancer screening and will add only a few minutes to the entire exam. However, the VELscope exam may or may not be covered by dental insurances. The fee for this enhanced examination is $35. As a part of our standard oral care, and because we care about you, we strongly recommend that you choose this additional screening procedure.  

Please sign the area below to accept the financial responsibility for this procedure.

  •  YES, I authorize the office to perform the VELscope examination.
  •  NO, I DO NOT authorize the office to perform the VELscope examination.
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Financial and or Insurance Policy Agreement( * mandatory to fill )
  •  I HAVE
  •  I HAVE NOT

Missed Appointments(without 24 notice) will incur a $100 fee.

It is my responsibility to understand my insurance plan: coverage, exclusions, and limitations. I will notify Lakeview Dental of any changes to my insurance prior to any scheduled appointments.

Lakeview Dental will provide me with an estimated co-pay for any treatment, however, I am responsible for the total cost of this treatment if my insurance does not pay.

Insurance will be billed on my behalf. If within 90 days my insurance has not paid, I will be asked to pay the balance in full. Lakeview Dental will then provide all information for me to submit the claim to get reimbursed.

If your account is sent to collections, there will be a 30% collection fee on top of what your balance is.

Payment is due at the time of service. All major credit cards, checks, cash, and care credit are accepted. Thank you

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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 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 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 person 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 health information or in response to a request 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 : 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.
**You may refuse to sign this acknowledgement.

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  •  I have read Lakeview Dental Office's Notice of Privacy Practice.
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