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South Shreveport dental

9220 Ellerbe Road, Suite 100,
Shreveport, LA 71106
(318) 868-0830

Patient Information( * mandatory to fill )
Responsible Party's Information( * mandatory to fill )
Emergency Contact Information( * mandatory to fill )
Primary Insurance Details( * mandatory to fill )
Medical History( * mandatory to fill )

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

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  •  Pregnant/trying to get pregnant?
  •  Nursing?
  •  Taking oral contraceptives?
  •  Aspirin
  •  Pencillin
  •  Codeine
  •  Acrylic
  •  metal
  •  Latex
  •  sulfa drugs
  •  Local anesthetics
  •  Other
Do you have, or have you had, any of the following?
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To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or my patients) health. It is my responsibility to inform the dental office of any changes in medical status.

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Our Policy Regarding Dental Insurance( * mandatory to fill )

You are fortunate to have dental insurance, whether you have purchased it or your employer has provided it for you. Though your dental insurance is your responsibility we can help! We will go the extra mile to help you maximize your benefits. As a courtesy, we will help by filing your insurance forms, which will save you considerable time and trouble. We accept payments from most insurance companies, which reduces your immediate out-of-pocket expense.

Regardless of what we may calculate your insurance company to pay, it is only an estimate. Our estimate is based on limited information obtained from your insurance company. You must understand, we cannot forecast what they will pay

 

We must stress that you are responsible for the total treatment fee. Your dental insurance is not designed to pay the entire cost of your treatment, but it is intended to help cover a certain portion of the cost.  A better term for dental insurance may be "dental assistance".

Please remember, however, the financial obligation for

dental treatment is between you and this office, and

 

is not between this office and your insurance company.

Dental insurance companies normally do not require a "predetermination" or "prior authorization". If the insurance company does we will be happy to submit a treatment plan to them.  In order for us to submit your form, we ask that you provide the following

1.   A copy of your insurance booklet OR insurance card.

 2.     A copy of a signed insurance information release form with the insured's birth date, social security number, group or ID number, and the name of the employee, whichever is applicable.

It often takes us a considerable amount of time to try to collect your insurance payment for you. We often need your help to discuss your situation directly with your insurance.

 I have read and understand the above.

  •  I authorize release of any information relating to my claim.
  •  I authorize payment directly to South Shreveport Dental
  •  I understand that all fees not paid by insurance are my responsibility.
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Financial Policy( * mandatory to fill )

Appointment Reservation

Our office is dedicated to quality care and exceptional service. We respect the importance of your time, and we work hard to schedule appointments that accommodate the scheduling needs of all of our patients. Broken and missed appointments create scheduling problems for other patients as well as the office. If you find that you must change your appointment, we require a minimum of 24 hour notice so that we are able to accommodate other patients needing your appointment time. Failure to provide 24 hour notice will result in a $50 account adjustment, which may or may not be applied to future balances at the sole discretion of management.

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Financial Obligation

As a courtesy to our patients who have dental benefits, we are happy to file your claims electronically from our office. We require payment towards services at the time the services are rendered. Please understand that it is your responsibility to know your specific plan/policy coverage. Your dental benefits may cover less or more than what we estimate or collect from you initially. Therefore, after we receive payment from your dental benefits provider, you will be responsible for the balance. Our office will send you a statement that is due within 30 days. Patients without dental benefits are required to pay in full at the time services are rendered unless other arrangements have been made.

Balances not satisfied within 90 days will be sent a notice that your account will be turned over to a collection agency within 10 days. If your account is turned over, a 30% fee will be added to your final balance before going to collections.

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Third Party Financial Payment Plan Options (i.e. Care Credit, Lending Club, etc.)

We understand that regardless of whether a patient has dental benefits, care, maintenance and treatment are necessary to maintain good overall health. Sometimes these expenses can be unexpected and costly. We are happy to offer Care Credit payment plans to all patients. Our office pays all fees and the interest up to 12 months. With their high acceptance rate, these plans offer no interest (up to 12 months) and low interest (up to 60 months) payment plan options.

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Returned Checks

A fee of $35.00 will be charged on all NSF returned checks.

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Treatment Plans

Treatment plan presentations include all of the expected procedures with their respective ADA CDT (current dental terminology) service codes. Please note, however, your treatment can unexpectedly change during a procedure.

Our office fees, estimated insurance, and patient responsibility is included on the form so that you can plan ahead, schedule your treatments in phases, and even contact your dental benefits provider to learn more about their estimated coverage. All treatment plan estimates are subject to change after 45 days. Please also remember we have no control or authority on the reimbursement rate of your dental insurance provider. The responsibility for payment is between you and this office, not this office and your dental benefit provider, although we work tirelessly to maximize your benefits and file your claims on your behalf. Not all insurance carriers are equal. Please see our policy regarding dental insurance.

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I Understand That Payment Is Due At Time Of Service.

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  •  CASH
  •  CHECK
  •  CREDIT CARD
  •  OTHER
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Notice of Privacy Practices( * mandatory to fill )

Notice of Privacy Practices for Protected Health Information

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

With your consent, the practice is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations.  Protected health information is the information we create and obtain in providing our services to you.  Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment.  It also includes billing documents for those services.

Example of uses of your health information for treatment purposes:

A nurse obtains treatment information about you and records it in a health record.  During the course of your treatment, the doctor determines a need to consult with another specialist in the area.  The doctor will share the information with such specialist and obtain input.

Example of use of your health information for payment purposes:

We submit a request for payment to your health insurance company.  The health insurance company requests information from us regarding medical care given.  We will provide information to them about you and the care is given.

 Example of Use of Your Information for Health Care Operations:

We obtain services from our insurers or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services.

Your Health Information Rights

 The health record we maintain and billing records are the physical property of the practice.  The information in it, however, belongs to you.  You have a right to:

Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office.  We are not required to grant the request but we will comply with any request granted;

Request that you be allowed to inspect and copy your health record and billing record—you may exercise this right by delivering the request in writing to our office;

Appeal a denial of access to your protected health information except in certain circumstances;

- Request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office;

File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information.

- Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office.  An accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing care;

- Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office; and,

Revoke authorizations that you made previously to use or disclose the information except to the extent information or action has already been taken by delivering a written revocation to our office.

If you want to exercise any of the above rights, please contact [insert name of designated staff member, phone number, or address], in person or in writing, during normal hours.  S[he] will provide you with assistance on the steps to take to exercise your rights.

Our Responsibilities

The practice is required to:

Maintain the privacy of your health information as required by law;

Provide you with a notice of our duties and privacy practices as to the information we collect and maintain about you;

Abide by the terms of this Notice;

Notify you if we cannot accommodate a requested restriction or request; and

Accommodate your reasonable requests regarding methods to communicate health information with you.

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain.  If our information practices change, we will amend our Notice.  You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our "Notice" or by visiting our office and picking up a copy.  

To Request Information or File a Complaint

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact [insert name, title, and telephone number of internal contact person]. 

 Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to [list internal staff member.]  You may also file a complaint by mailing it or e-mailing it to the Secretary of Health and Human Services whose street address and e-mail address is [insert street and e-mail addresses.]

We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the practice. 

We cannot, and will not, retaliate against you for filing a complaint with the Secretary. 

 Other Disclosures and Uses

Notification

Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.

Communication with Family

Using our best judgment, we may disclose to a family member, other relatives, close personal friend, or any other person you identify, health information relevant to that person's involvement in your care or in payment for such care if you do not object or in an emergency.

Food and Drug Administration (FDA)

We may disclose to the FDA your protected health information relating to adverse events with respect to products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.

Workers Compensation

If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

Public Health

As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Abuse & Neglect

We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.

Correctional Institutions

If you are an inmate of a correctional institution, we may disclose to the institution, or its agents, your protected health information necessary for your health and the health and safety of other individuals.

Law Enforcement

We may disclose your protected health information for law enforcement purposes as required by law, such as when required by court order, or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement.

Health Oversight

Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.

Judicial/Administrative Proceedings

We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order.

Other Uses

Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided.

Website
If we maintain a website that provides information about our entity, this Notice will be on the website. 
I,

hereby acknowledge that I have received a copy of this practices Notice of Privacy Practices.  I have been given the opportunity to ask any questions I may have regarding this Notice.

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