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Woburn Dental Associates

26 Warren Avenue,
Woburn, MA, 01801
7812414288

Patient Information( * mandatory to fill )
Responsible Party's Information(if someone other than the patient)( * mandatory to fill )
Primary Insurance Details( * mandatory to fill )
  •  Yes
  •  No
Secondary 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
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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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Financial Agreement( * mandatory to fill )

In an effort to maintain treatment fees at a minimum while maintaining a high level of professional care, we have established the following financial policy for our office. Please feel free to discuss our fees with us at any time. Before any dental treatment is begun, the patient and/or responsible party will receive a consultation regarding treatment plan and cost.

We require payment in full for the portion, not covered by dental insurance, of dental services to be rendered. For procedures that take multiple appointments to complete, payment may be split up over the number of appointments required. Any other financial arrangements shall be made only at the finance manager and/or doctor's discretion. We accept cash, checks, Amex Visa, MasterCard, Discover, and upon request, we can also provide information regarding financial companies to help assist with the cost of your dental procedures such as Care Credit, and Citi Health. Credit applications for such financing options are available upon request.

 As a courtesy to our patients with insurance, we will file your insurance claim, allowing you to pay only your deductible and/or estimated co-payment as services are rendered. Please remember that the contract is between you and your insurance company and your total balance in our office is always your responsibility. Please note that we allow 60 days for the dental claim to be paid. We make every effort to give you an accurate estimate of what your portion of our fees will be, based on the information provided to us. However, we have no way to guarantee the actual terms of your policy. If for any reason there is a balance remaining after your insurance company's payment, you will be sent the statement. Any dispute regarding reimbursement or the amount of reimbursement is between you and your insurance carrier. By agreeing to this policy you agree to all such conditions.

We schedule our appointments to provide each patient with our undivided attention. In order to accomplish this, please be advised that you will be charged for cancellations with less than 24 hours notice at the rate of $50.00 for examination/hygiene appointments and $75.00 for dental procedures appointments. Also, note that any type of deposits and/or payments towards the cosmetic cases will not be refunded. Should the patient change their mind for whatever reason during treatment, the patient will be responsible for all costs incurred including lab fees and related costs.

 An account with an unpaid balance past 60 days will be sent to a collection agency. At that time, you will be responsible for any and all costs incurred in the collection of your debt from the last date of services, such as attorney fees, court fees and any other fees associated with the collection of your debt

Original records including radiographs are the property of this office. If you desire, we will provide you with a copy of your record or radiographs for a nominal duplication fee of $25.

We appreciate your confidence in choosing our practice. Please do not hesitate to inquire with a staff member should you have any questions regarding this policy.

 I have read, understood, and agree to the Office Financial Policy stated above.

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HIPAA Information and Consent Form( * mandatory to fill )

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 patient's 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 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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