Patient Registration Patient Details

Patient Registration Contact Information

  •  E-Mail
  •  Cell Phone
  •  Home Phone

Emergency Contact Information

Patient Registration Medical History

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  •  Aspirin
  •  Erythro
  •  Latex
  •  Sulfa Drugs
  •  Codeine
  •  Hay Fever
  •  Penicillin
  •  Other

Do you have or have you had any of the following medical conditions?

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Nearest Relative not living with you

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Patient Registration Dental History

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  •  Pain avoidance
  •  Oral Cancer
  •  Appearance
  •  Wasting/Exceeding Dental Insurance Limits
  •  Losing teeth
  •  Your general health
  •  Gums/Periodontal Disease
  •  Routine check up
  •  Cavities
  •  Cleaning
  •  Other
  •  More Attractive Smile
  •  Implants
  •  Veneers
  •  Bad Breath Treatment
  •  Fixing Chipped Teeth
  •  Replacing Missing Teeth
  •  Preventing Cavities

Treatment Authorization

I authorize and give consent to perform dental services agreed between doctor and patient and/or parent or guardian to be necessary as advisable; including the use of local anesthesia and other medication as indicated. I certify to the above statements regarding my medical condition.

I also understand that payment for all treatment and services rendered is my responsibility.

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Patient Registration Insurance Authorization

I hereby authorize payment directly to the dental office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs and dental treatment. I hereby authorize the dental office to administer such medications and perform such diagnostic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the medical history is correct to the best of my knowledge.

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Patient Registration Patient Agreement

At Wellness Dental, we believe that you deserve the best care. That's why we always present you with the best dental solution possible to treat your personal situation.

We work with thousands of insurance companies. Although we can maintain computerized history of payment by a given company, fees do change regularly; therefore it is impossible to give you a guaranteed quote at the time of service. we estimate your portion based on the most up-to-date information we have, but it is ONLY AN ESTIMATE. As a courtesy, we bill your insurance for you. we are a 'fee for service' establishment, so payment will be due at the time of treatment.

We welcome you to our family and look forward to helping you get the healthy, beautiful smile you've always wanted. If there is anything we can do to make your visits here more pleasant, please don't hesitate to ask one of our staff members.

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Patient Registration Statement of Office Protocol

FINANCIAL POLICY

Thank you for choosing our office as your dental health care provider. We are committed to providing you with the highest quality dental care, so that you may attain optimum oral health. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our financial policy, which we require that you read, agree to, and sign prior to any treatment.

Payment is due at the time service is provided. Our office accepts cash, personal checks, VISA/MC/Discover and Automatic Credit Card Authorizations, as well as in house financing.

If you have insurance benefits we ask that you pay the deductible and the estimated co-payment at the time of service. We will submit the insurance claims as a courtesy to you; however, your insurance contract is between you and your insurance company. All patients are financially responsible for their accounts. The insurance company is responsible for the patient. We want to emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company.

All charges you incur are your responsibility regardless of your insurance benefits. We will cooperate fully with the regulations and requests of your insurance company that may assist in the claim being paid. Our office will not, however, enter into a dispute with your insurance company over any claim. If problems arise in getting a claim paid, specific questions should be directed to your insurance carrier or employer.

Insurance payments are ordinarily received within 20-60 days from time of filing. If your insurance company has not made payment within 30 days, we will ask that you contact your insurance company to make sure payment is expected. If payment is not received within 60 days from the date of filing, or your claim is denied, you will be responsible for paying the full amount at that time. If we receive any payments from your insurance company after you have paid in full, we will remit the payments directly to you.

We do not accept personal checks.

CANCELLATION POLICY

We respect the importance of your time and we work very hard to schedule appointments that accommodate the scheduling needs of all of our patients. We want you to know that we make every effort to see you at your scheduled appointment time. Unlike other dental practices, we do not double book appointments; in fact, we allow a generous amount of time for both appointments and procedures. We feel that a successful outcome to treatment is the result of the combined efforts of both you and this office. Therefore, it is important to adhere to the recommended treatment schedule to obtain optimum results. Broken, missed, as well as late arrivals create scheduling problems for other patients as well as the practice. Appointments are considered reservations and you will receive a reminder call prior to this appointment.

If it is necessary to cancel your scheduled appointment, we require that you notify our office at least 48 hours in advance. Appointments are in high demand, and your early cancellation will allow another patient access to timely care. Late cancellations or no-shows to your confirmed appointment will result in a $50.00 bills office fee. Please confirm 48 hours prior to scheduled appointments. Unconfirmed appointments 48 hours prior may be reallocated to someone who is in need of treatment. We ask for your careful consideration regarding this matter. In return, we promise to provide you with the very best dental care.

I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE TERMS AND CONDITIONS REGARDING THE FINANCIAL AND APPOINTMENT POLICY FOR THIS PRACTICE. I AUTHORIZE MY INSURANCE COMPANY TO PAY MY DENTAL BENEFITS DIRECTLY TO MY DENTAL OFFICE.

  •  Yes
  •  No
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Patient Registration HIPAA

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.

We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 09/23/2013 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, and to make new Notice provisions effective for all protected health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new Notice 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.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

We may use and disclose your health information for different purposes, including treatment, payment, and health care operations. For each of these categories, we have provided a description and an example. Some information, such as HIV-related information, genetic information, alcohol and/or substance abuse records, and mental health records may be entitled to special confidentiality protections under applicable state or federal law. We will abide by these special protections as they pertain to applicable cases involving these types of records.

Treatment. We may use and disclose your health information for your treatment. For example, we may disclose your health information to a specialist providing treatment to you.

Payment: We may use and disclose your health information to obtain reimbursement for the treatment and services you receive from us or another entity involved with your care. Payment activities include billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your dental health plan containing certain health information.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations.For example, healthcare operations include quality assessment and improvement activities, conducting training programs, and licensing activities.

Individual involved in Your care or payment for Your care: We may disclose your health information to your health information to your family or friends or any other individual identified by you when they are involved in your care or in the payment for your care. Additionally, we may disclose information about you to a patient representative. If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information.

Disaster Relief: We may use or disclose your health information to assist in disaster relief efforts.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Public Health Activities: We may disclose your health information for public health activities, including disclosures to:
* Prevent or control disease, injury or disability;
* Report child abuse or neglect;
* Report reactions to medications or problems with products or devices;
* Notify a person of a recall, repair, or replacement of products or devices;
* Notify a person who may have exposed to a disease or condition; or
* Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.

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 the protected health information of an inmate or patient.

Secretary of HHS: We will disclose your health information to the Secretary of the U.S. Department of Health and Human Services when required to investigate or determine compliance with HIPAA.

Worker's Compensation: We may disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to worker's compensation or other similar programs established by law.

Law Enforcement: We may disclose your PHI for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order.

Health Oversight Activities: We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Judicial and Administrative Proceedings: If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about the request or to obtain an order protecting the information requested.

Research: We may disclose your PHI to researcher when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information.

Coroners, Medical Examiners, and Funeral Directors: We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties.

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