Summit Family Dentistry-NEW PATIENT FORMS

NEW PATIENT FORMS Patient Information Form

WELCOME TO OUR PRACTICE

First Name*

Last Name*

Middle Name

Date Of Birth*

Social Security Number*

Previous Visit

Gender*

Marital Status*

Driving License Number

Best time to call

Email*

Home Phone Number

Cell Phone Number*

Work Phone Number

Work Ext

Fax

Other

Address*

City*

State*

Zip*

I prefer to be contacted by

Cell phone/Text
Email
Home Phone
Leave a message

How did you hear about our office?*

In an emergency, who should be notified? Please enter name, phone number and relationship below

DENTAL INFORMATION

How would you rate the condition of your mouth?

Excellent
Good
Fair
Poor

Previous Dentist Name and Phone Number

Approximate date of most recent dental exam and/or dental x-rays

I routinely see a dentist every

3 mos
4 mos
6 mos
12 mos
Not routinely

What is your immediate concern about your dental health?

Is there anything about the appearance of your smile that you would like to change?

If any of the checked boxes need further explanation, Please Describe

CONSENT FOR INTERNET COMMUNICATIONS

I grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured web site for the dental practice. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice web site with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns.

I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the web site on my behalf. I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES.

* I have read the information above regarding the secured uploading of patient information to the web site for the dental practice, and grant the dental practice permission to securely upload my patient information to the web site.

SIGNATURE (Patient Signature)*

(Please click below to draw/upload sign)

(Your IP Address :IP:3.236.159.130 )

NEW PATIENT FORMS Insurance And Financial Form

Do you have Dental Insurance?

Yes
No

As a courtesy, our office will submit Insurance claims for you in most cases. If you do not have insurance, please respond "N/A".

Name of Policy Holder

Policy holders date of birth

ID #

Group #

Insured's Address

City

State

Zipcode

Insured's Employer Name

Employer Address

City

State

Zipcode

Patient's relationship to insured

Self
Spouse
Child
Other

Insurance Plan Name

Insurance Address

City

State

Zipcode

Policy Holder SS#

Phone

Do you have secondary dental insurance?

Yes
No

SIGNATURE (Patient Signature)*

(Please click below to draw/upload sign)

(Your IP Address :IP:3.236.159.130 )

NEW PATIENT FORMS Financial Agreement

Financial Responsibility, Assignment Of Insurance And Release

As a courtesy to the providers scheduled and the needs of other patients, I acknowledge that I will be charged $50 for a missed appointment or cancellation when providing less than 48 hours' notice. Additionally, I will be charged a $50 returned payment fee for any payment that is returned by my financial institution to Summit Family Dentistry as nonpayment. I have reviewed Summit Family Dentistry's financial policy. I acknowledge and agree to these terms and conditions.

I accept financial responsibility for all charges incurred during treatment whether or not they are covered by insurance. If I have insurance coverage as listed above, I assign Summit Family Dentistry any insurance benefits for services rendered. I authorize a release of all information necessary to secure payment and authorize the use of the below signature on all insurance forms. All accounts that become 30 days delinquent are subject to a 1.5% finance charge per month on the past due amount. This is an annual percentage rate of 18%.

SIGNATURE (Patient Signature)*

(Please click below to draw/upload sign)

(Your IP Address :IP:3.236.159.130 )

NEW PATIENT FORMS HIPPA Release Form

MEDICAL INFORMATION RELEASE FORM

I authorize the release of information including the diagnosis, records, examination rendered to me and claims information, This information may be released to

Spouse
Child(ren)
Other
Information should not be released to anyone.

Contact name

This release information will remain in effect until terminated by me in writing.

Contact Information

I authorize Summit Family Dentistry to contact me at the phone numbers, emails, and any additional contact information provided by the office.

Acknowledgment of the Receipt Of Notice Of Privacy Practice

I acknowledge that I have been presented a copy of Summit Family Dentistry's Notice of Privacy Practices, which has an effective date of 09/22/2013 and which describes how my health information may be used and disclosed (Copies available in office and online). I understand that you have the right to change The Notice of Privacy Practices at any time, that I will be provided a copy of any updated version, and that I may contact you at any time to request a current Notice of Privacy Practices.

My signature below acknowledges the authorization of release of information, the authorization for leaving voicemail, and that I have been presented with a copy of the Notice of Privacy Practices. Note: You will electronically sign this form in our office.

SIGNATURE (Patient Signature)*

(Please click below to draw/upload sign)

(Your IP Address :IP:3.236.159.130 )

NEW PATIENT FORMS Patient Information Form

NEW PATIENT FORMS Insurance And Financial Form

NEW PATIENT FORMS

NEW PATIENT FORMS Financial Agreement

NEW PATIENT FORMS Medical History

NEW PATIENT FORMS HIPPA Release Form

Contact Information

Acknowledgment of the Receipt Of Notice Of Privacy Practice

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