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Riverwalk Dental Group Stuart

6513 S. Kanner Highway,
Stuart, FL, 34997
(772) 252-1058

PATIENT INFORMATION( * mandatory to fill )

Welcome to our office. We appreciate the confidence you place with us to provide dental services. To assist us in serving you, please completed the following form. The information provided on this form is important to your dental health. If there have been any changes in your health, please tell us. If you have any questions, don't hesitate to ask. 

Contact Information( * mandatory to fill )
Emergency Contact Information( * mandatory to fill )
Insurance Details( * mandatory to fill )
DENTAL HISTORY( * mandatory to fill )
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MEDICAL HEALTH HISTORY( * mandatory to fill )

Do you have, or have you had any of the following? 

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Women 

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During the past 12 months, have you taken any of the following? 

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Are you allergic to : 

  •  Penicillin
  •  Latex
  •  Local anesthetics (\'Novocaine\')
  •  Penicillin or other antibiotics
  •  Sulfa drugs
  •  Barbiturates, sedatives, or sleeping pills
  •  Aspirin, Acetaminophen, or Ibuprofen
  •  Codeine, Demerol, or other narcotics
  •  Reaction to metals
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Financial Policy

Please read carefully and sign to acknowledge understanding and agreement

Thank you for choosing us as your dental care provider. We are committed to providing you with the best dental care available.

Available Payment Options.

You can choose from ~ Cash, Check, Visa, Mastercard, American Express

CareCredit payment plan option, ask us for detailed information.

Regarding Insurance.

  • For covered services, we ask that all co-pays and deductibles be paid on the day of treatment. Since your insurance company may not cover all costs, we ask that you pay any percentage of your balance not paid by your insurance on the day of treatment.
  • For services that are not covered by your insurance, we ask that you pay the entire fee the day of your treatment.
  • We will attempt to answer any questions we can about your insurance and, when possible We will assist in resolving complications with your insurance company. Please understand that We cannot Speak on their behalf. Your insurance contract is an agreement between you, your employer and your insurance carrier. In the event that your insurance company has not paid (on your behalf), you will be responsible to pay your account.

Patients Without Insurance.

  • For those patients without insurance coverage, you will be responsible for payment on the day of treatment. If you are not able to pay in full, or if your treatment requires several visits, you will be given an estimate and will be able to discuss payment arrangements with a member of our business office Staff.

Cancellation/No Show Policy.

  • Our office requires notice to cancel your appointment in the case of an emergency.
  • There will be a cancellation fee up to $50 for appointments cancelled in less than 24 hours.

Collections

  • A charge will be added to your account for any returned checks. You are responsible to pay all costs of collecting, or attempting to collect any debt owed on this account. This includes all attorneys fees, interest, and late fees.

X-Rays.

  • You are responsible to pay a fee for duplicate copies of your X-rays.

I hereby authorize payment to Riverwalk Dental Group Stuart by the group insurance, otherwise payable to me.

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HIPAA Compliance

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 patients 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 the 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 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 the 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, 

on this date 

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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Doctor Patient Arbitration

The doctor and the undersigned patient have agreed:

Article 1: Agreement to Arbitrate: The parties to this agreement are Doctor and Patient. It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improper, negligently or incompetently rendered, will be determined by submission to arbitration and not by a lawsuit or resort to court process except as state law provides for judicial review or arbitration proceedings. BOTH PARTIES TO THIS CONTRACT, BY ENTERING INTO IT, ARE GIVING UP THEIR CONSTITUTIONAL RIGHTS TO HAVE ANY SUCH DISPUTE DECIDED IN A COURT OF LAW BEFORE A JURY AND INSTEAD ARE ACCEPTING THE USE OF ARBITRATION.

Article 2: All Claims Must Be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of the related treatment of services provided by the Doctor including any spouse or heirs of the Patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim in the case of any pregnant mother. The term “Patient” herein shall mean both the mother and the mothers expected child or children.

THE SOLE METHOD FOR RESOLVING SUCH DISPUTE SHALL BE BY BINDING ARBITRATION ADMINISTERED BY THE AMERICAN ARBITRATION ASSOCIATION in accordance with the Commercial Arbitration Rules of the American Arbitration Association. The parties hereby agree that they shall submit their controversy to an Arbitrator who is a dentist licensed in the state of Florida.

All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the Doctor and the Doctors partners, associates, association, corporation or partnership, and the employees, agents, and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the Doctor to collect any fee from the Patient shall not waive the right to compel arbitration of any medical malpractice claim. However, following the assertion of any claim against the Doctor, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.

 

ARTICLE 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty (30) days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty (30) days thereafter. Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in any court action, and upon such intervention and joinder, any existing court action against such additional person or entity shall have stayed pending arbitration.

ARTICLE 4: Payment of Arbitration Costs: The prevailing party in any arbitration pursuant to this agreement shall be awarded all costs, including reasonable attorneys fees and the arbitrators fees, in prosecuting or defending the claim in arbitration, but not to exceed, $2,500 in amount. Furthermore, if any action is undertaken to set aside or otherwise attack the binding arbitration award, the losing party in the court action shall bear all the prevailing partys costs, including reasonable attorneys fees.

ARTICLE 5: Future Services: This agreement shall govern all future services rendered to Patient by Doctor and Doctors Partners, Affiliates and Associates. Execution of this agreement is a precondition to the furnishing of services by Doctor, but this agreement may be rescinded by written notice by either party within thirty days of signature. After those thirty days, this agreement may be changed or revoked only by a written revocation signed by both parties.

IT IS UNDERSTOOD BY THE PATIENT THAT HE OR SHE IS NOT REQUIRED TO USE THE UNDERSIGNED DOCTOR AND THAT THERE ARE NUMEROUS OTHER DOCTORS IN THE IMMEDIATE AREA WHO ARE QUALIFIED TO PROVIDE THE SAME SERVICES.

ARTICLE 6: General Provisions: All claims based upon the same incident, transaction, or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable state statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence.

ARTICLE 7: No Other Representations: Except for the fact that the Doctor has indicated professional services will not be rendered to Patient unless this agreement is executed, the Doctor has made no other representations or statements, oral or written, to induce the patient to execute this agreement.

ARTICLE 8: Revocation: This agreement may be revoked by written notice delivered to the Doctor within 30 days of signature and if not revoked will govern all medical services received by the patient.

ARTICLE 9: Retroactive Effect: If a Patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment) Patient should sign below.

Effective as of the date of first Doctor Services.

If any provision of this Doctor-Patient Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the individuality of any other provision.

THIS IS A BINDING LEGAL DOCUMENT WHICH MAY HAVE AN IMPORTANT EFFECT ON YOUR LEGAL RIGHT. CONSULT YOUR ATTORNEY ON ANY QUESTIONS YOU MAY HAVE.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

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Photo Consent Form

May we show you off?

Riverwalk Dental Group Boynton Beach is committed to providing the highest quality care for each and every one of our patients. On occasion, a case comes along that we take particular pride in and would like to use to show other patients when presenting their treatment options. Unless otherwise specified, all photographs are anonymous- meaning it’s just your smile and/or teeth, not your whole face.

 Photo Consent Form

I hereby give Riverwalk Dental Group Boynton Beach and any and all employees and/or agents of Riverwalk Dental Group Boynton Beach the right and permission to use and/or publish photographs of me for art, promotional and educational purposes (including but not limited to, advertising, publicity, commercial or display of use).

 Release of Claims:

I hereby release and discharge Riverwalk Dental Group Boynton Beach and all persons functioning under his/her permissions or authority from any legal or equitable claims including but not limited to the following: blurring of the image(s), alteration, distortion or use in composite form, libel, invasion of privacy or any claims based on the production or in the process of recording or publishing the materials.

  •  Yes, you may use my photos
  •  No, please do not use my photos
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HIPAA Compliance-Patient Consent Form

The Department of Health and Human Services has established a "Privacy Rule" to help ensure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients' consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations.

As our patient we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care Information and information about treatment, payment or health care operations in order to provide health care that is in your best interest.

We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients) and may have to disclose personal health information for purposes of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent.

You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent.

You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice.

COMPLIANCE ASSURANCE NOTIFICATION FOR OUR PATIENTS

 To Our Valued Patients: 

 The misuse of Personal Health Information (PHI) has been identified as a national problem causing patients inconvenience, aggravation, and money. We want you to know that all of our employees, managers, and doctors continually undergo training so that they may understand and comply with government rules and regulations regarding the Health Insurance Portability and Accountability Act (HIPAA) with particular emphasis on the "Privacy Rule." We strive to achieve the very highest standards of ethics and integrity in performing services for our patients.

 It is our policy to properly determine the appropriate use of PHl in accordance with government rules, laws and regulations. We want to ensure that our practice never contributes in any way to the growing problem of improper disclosure of PHI. As part of this plan, we have implemented a Compliance Program that we believe will help us prevent any inappropriate use of PHI. We also know that we are not perfect Because of this fact, our policy is to listen to our employees and our patients without any thought of penalization if they feel that an event in any way compromises our policy of integrity. More so, we welcome your input regarding any service problem so that we may remedy the situation promptly,

 

Thank you for being one of our highly valued patients

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Informed Consent

 Potential Risks and Limitations Of Dental Treatment

As a rule, excellent dental results can be achieved with informed and cooperative patients. Thus, the following information is routinely supplied to anyone considering dental treatment in our office recognizing the benefits of a pleasing smile and healthy teeth, you should also be aware that dental treatment, like any treatment of the body, has some inherent risks and limitations. These risks and limitations usually do not contra-indicate treatment but should be considered in making the decision to submit to dental treatment.

Perfection is our goal. However, in dealing with human beings, and problems of growth and development, the ravages of dental disease, genetics, and patient cooperation, achieving perfection is not always possible. Often a functionally and esthetically adequate result must be accepted. We will do everything within our capacity to ensure the best possible care.

Throughout life, teeth are constantly changing. Periodic examinations should be made so any disease can be treated promptly. Frequent professional visits are the best insurance against serious dental disease. Decay or gum disease can occur if patients do not brush and floss their teeth properly and thoroughly. Excellent oral hygiene and plaque removal is a must.

On rare occasions, the nerve of a tooth may die and become infected. A tooth that has been damaged by deep decay, a minor blow or extensive dental treatment can die over a long period of time. An undetected non-vital tooth may flare up during any dental treatment and may require endodontics (root canal) treatment to maintain it. It may even have to be removed. There is also a risk that during or following treatment soreness or tenderness may occur in the temporomandibular joints (lower jaw joints).

The total time for treatment can be delayed beyond our estimate.

Treatment plans can change due to altered conditions which may surface during treatment. Decay which may appear small on x-ray may be larger than anticipated resulting in much more extensive treatment.

 

Informed Consent

I understand that during treatment occasionally any of the above problems may occur. These can include but are not necessarily limited to pain (discomfort), tooth mobility, tooth decay, devitalization (nerve loss), tooth and/or jaw changes, and injury resulting from the use of high-speed dental equipment. 

I understand that treatment alternatives will be explained (including the consequences of no treatment) as well as the preferred method of treatment for my mouth. I understand that for a successful result and to lessen the dangers of complication, the following conditions are essential on my part:

1. Excellent oral hygiene

2. Proper diet controls

3. Strict adherence to instructions

4. Cooperation in keeping appointments

I understand that there is no warranty or guarantee to my result and/or care, I also understand that I can, at any time, ask for and receive a full recital of all possible risk related to my treatment.

In addition, I understand that treatment may be discontinued for patients who fail two appointments without prior notification: who are constantly late for their appointments: who continue to excessively cancel their appointments: who fail to practice acceptable oral hygiene: or who are uncooperative with staff providing care.

 

 

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Cancellation Policy

24 Hour Appointment Policy

We require a minimum of twenty-four (24) hours advance notice of cancellation. Patients who do not provide twenty-four (24) hours advance notice of cancellation or do not present for a scheduled appointment may be subject to a charge of up to $50 per appointment. 

It is also our policy not to schedule any patients who have three (3) or more broken appointments within a year.

 

Our purpose is to truly serve you as we meet your needs and exceed your expectations. We have the utmost respect for you and would like to continue providing your dental needs.  We at Riverwalk Dental Group strive to do everything in our power to leave our patients feeling satisfied.   

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