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Midtown Modern Dentistry

9439 Forest City Cove, Suite 1070,
Altamonte Springs, FL 32714
(407) 706-7000

Patient Details( * mandatory to fill )
  •  Home Phone
  •  Work Phone
  •  Wireless Phone
  •  Email
  •  Home Phone
  •  Work Phone
  •  Wireless Phone
  •  Email
  •  Home Phone
  •  Work Phone
  •  Wireless Phone
  •  Email
  •  Non student
  •  Fulltime
  •  Partime
  •  Check box if same for entire family
( * mandatory to fill )

INSURANCE POLICY 1

  •  Self
  •  Spouse
  •  Child
  •  Other

Please present Insurance Card to Receptionist

INSURANCE POLICY 2

  •  Self
  •  Spouse
  •  Child
  •  Other
DENTAL HISTORY FOR NEW PATIENT( * mandatory to fill )
  •  Yes
  •  No
  •  Time
  •  Fear
  •  Cost
  •  Other
  •  Yes
  •  No
  •  Yes
  •  No
  •  Senstivity
  •  Bleeding or irritated gums
  •  Tooth pain when chewing
  •  Loose , tipped or shifting
  •  Teeth or filling breaking
  •  Dry Mouth
  •  Jaw joint pain
  •  Bad breath or taste
  •  Grinding or clenching teeth
  •  Treatment for TMJ
  •  Wear night guard ?
  •  Braces
  •  Yes
  •  No
  •  Upper
  •  Lower
  •  Yes
  •  No
  •  Yes
  •  No
  •  Make them whiter
  •  Alternative to denture
  •  Replace missing teeth
  •  Close spaces
  •  Get a smile makeover
  •  Replace old crowns that dont match
  •  Repair chipped teeth
  •  Make them straighter
  •  Replace metal color fillings with tooth colored fillings
  •  Yes
  •  No
MEDICAL HISTORY( * mandatory to fill )
  •  Anesthetic
  •  Iodine
  •  Aspirin
  •  Latex
  •  Codeine
  •  Penicillin
  •  Ibuprofen
  •  Sulfa

Check if you have any of the following medical 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
HIPPA ( * mandatory to fill )

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. This Notice takes effect April 14, 2003, 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 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 a 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. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $1.00 for each page, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)

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, but not before April 14, 2003. 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 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.

Contact Officer: George Sonbol

Telephone: 407-706-7000

E-mail: info@midtownmoderndentistry.com

Address: 9439 Forest City Grove #1070, Altamonte Springs, FL, 32714

I have had full opportunity to read and consider the contents of the Notice of Privacy Practices. I understand that I am giving my permission to your use and disclosure of my protected health information in order to carry out treatment, payment activities, and healthcare operations. I also understand that I have the right to revoke permission.

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FINANCIAL AGREEMENT( * mandatory to fill )

Thank you for choosing our office for your dental needs. We realize that every person's financial situation is different and we have found that our patients appreciate knowing exactly what to expect from us both from a philosophy aspect and a financial aspect. For this reason, we have worked hard to provide a variety of payment options to help you receive the dental care you need and deserve to enjoy a healthy, beautiful smile with respect to your budget. We are always available to answer any questions or assist you in any way we can.


Payment of estimated patient portion is due at the time of treatment. We desire to make dental treatment affordable to all of our patients. Therefore, we offer the following payment options:

1) We accept the following forms of payment: Cash, Check, Visa and MasterCard.

2) Flexible payment plans of up to 6 months upon approval with Care Credit®. Approval must be received prior to treatment date.


Payment for services is due at the time services are rendered unless prior arrangements have been made with the doctor and the billing person.


If dentures, partial dentures, crowns and/or bridges, retainers, mouthguards or nightguards are to be fabricated by a dental laboratory, a 50% deposit will be required at the time of the first impression. The remaining balance is due at the time the prosthesis is cemented or inserted.


The parent that accompanies the minor child/children to the appointment is responsible for any payment due. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized before the appointment date or previous arrangements have been made with the doctor and billing receptionist.


Checks that are returned to our office from your financial institution are subject to a $30.00 returned check fee. This fee covers the processing fees that are charged to our office.

 


Dental Insurance: Most Insurance companies will not cover 100% of all dental expenses. Your portion, not covered by insurance, is due at the time treatment is performed. Please understand that dental insurance is a contract between the patient and the insurance carrier, and not between the insurance carrier and the dentist. The patient is still the responsible party regarding dental fees. We will be glad to process your insurance forms at no charge.


Dental Insurance Estimates:


Most insurance companies will not cover 100% of all dental expenses. Your portion, not covered by insurance is due at the time treatment is performed. If there is a balance due after your insurance company pays their portion, you will be billed for any amount unpaid. You are responsible for any charges exceeding your benifits. Our office will assist in making collections from the insurance company by filing the necessary forms. A 1.5% monthly interest charge (18% APR) will be applied to ALL BALANCES PAST 60 DAYS DUE.


Please feel free to contact us if you have any questions or concerns regarding dental treatment or financial arrangements.


Thank you for choosing our office for your dental needs. We realize that every person's financial situation is differen and we have found that our patients appreciate knowing exactly what to expect from us both from a philosophy aspect and a financial aspect. For this reason, we have worked hard to provide a variety of payment options to help you receive the dental care you need and deserve to enjoy a healthy, beautiful smile with respect to your budget.


We are always available to answer any questions or assist you in any way we can. Payment of estimated patient portion is due at the time of treatment. We desire to make dental treatment affordable to all of our patients. Therefore, we offer the following payment options:


1) We accept the following forms of payment: Cash, Check, Visa and MasterCard.

2) Flexible payment plans of up to 6 months upon approval with Care Credit®. Approval must be received prior to treatment date.


Payment for services is due at the time services are rendered unless prior arrangements have been made with the doctor and the billing person.


If dentures, partial dentures, crowns and/or bridges, retainers, mouthguards or nightguards are to be fabricated by a dental laboratory, a 50% deposit will be required at the time of the first impression. The remaining balance is due at the time the prosthesis is cemented or inserted. The parent that accompanies the minor child/children to the appointment is responsible for any payment due. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized before the appointment date or previous arrangements have been made with the doctor and billing receptionist.


Checks that are returned to our office from your financial institution are subject to a $30.00 returned check fee. This fee covers the processing fees that are charged to our office.


Dental Insurance : Most Insurance companies will not cover 100% of all dental expenses. Your portion, not covered by insurance, is due at the time treatment is performed. Please understand that dental insurance is a contract between the patient and the insurance carrier, and not between the insurance carrier and the dentist. The patient is still the responsible party regarding dental fees. We will be glad to process your insurance forms at no charge.


Dental Insurance Estimates:

 

Most insurance companies will not cover 100% of all dental expenses. Your portion, not covered by insurance is due at the time treatment is performed. If there is a balance due after your insurance company pays their portion, you will be billed for any amount unpaid. You are responsible for any charges exceeding your benifits. Our office will assist in making collections from the insurance company by filing the necessary forms. A 1.5% monthly interest charge (18% APR) will be applied to ALL BALANCES PAST 60 DAYS DUE.


Please feel free to contact us if you have any questions or concerns regarding dental treatment or financial arrangements.

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CANCELLATION AND MISSED APPOINTMENT POLICY( * mandatory to fill )

When our office books your appointment, we are setting aside a dedicated chair and time slot just for you. We only ask that if you must reschedule your appointment, that you please provide us with at least 48 hours notice. This courtesy makes it possible to give your reserved time slot to another patient who would be more than happy to accept.

Every patient in our practice receives this unique reservation. When your appointment is made,a time is reserved, your materials are ordered, and we make special arrangements to be ready for your visit. Except for emergency treatment for another patient, you can expect us to be prompt. We, of course, would appreciate the same courtesy from you.

We will send out text reminders and emails to remind you of your appointment. We will also be confirming your appointment by email and text and we expect you to either CONFIRM OR CANCEL your appointment.

CANCELLATION OF AN APPOINTMENT: If it is necessary to cancel your scheduled appointment, we ask that you call at least 48 hours in advance. Please call (407)706-7000. If you do not reach the receptionist, you may leave a detailed message including your phone number. We will return your call as soon as possible and give you the next available appointment time. Appointments are in high demand and your early cancellation will give another patient the opportunity to be treated.

MISSED APPOINTMENT POLICY: A failure to be present at the time of a scheduled appointment will be recorded in your medical record as a "Missed Appointment". We reserve the right to charge $35 for a "Missed Appointment".

CONTINUED MISSED APPOINTMENTS: Dismissal from our Dental Practice.
*If you miss your initial (first) appointment with our office, we reserve the right to not reschedule you.

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