Patient Registration/Financial Policy

Transcription

1 Patient Registration/Financial Policy Date: Patient Information First Name: Last Name: Middle Initial: Preferred Name: Parent/Legal Guardian(s) if under the age of 18: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Would you prefer /text confirmations yes no Birth Date: Social Security #: Sex: ο M ο F Relationship to Insured: ο Self ο Spouse ο Child Marital Status: ο Married ο Single ο Divorced ο Separated ο Widowed Emergency Contact Name and Number Previous Dentist How did you hear about us? ο Insurance ο Internet ο Website ο Friend ο Relative ο Signage ο Other Are there any changes you would like to make to your smile? Primary Dental Insurance Information Name of Insured: First Name: Last Name: Middle Initial: Insured Soc. Sec. Insured DOB: Employer: Insurance Company: Address: ID # Address 2: Group #: City, State, Zip: Insurance Telephone #: Employment Status: ο Full Time ο Part Time ο Retired **If you have Secondary Insurance, please inform the receptionist. Financial Policy: PAYMENT IS DUE AT THE TIME OF SERVICE. The full balance of treatment is due at the time service is rendered. Payment plans are available through Care Credit and we also accept cash, check, Visa and MasterCard. Assignment of Dental Insurance Benefits Our office files insurance benefits as a courtesy to you. Claims unpaid by your insurance company after 60 days are your responsibility and will be due in full. All deductibles, copayments, and noncovered fees are due at the time of service. A CURRENT copy of your insurance card must be kept on file to utilize this service. Our office reserves the right to discontinue and/or refuse to file claims. Service Charges A $25 fee will apply to all returned checks. A fee of $50 will be charged for appointments cancelled with less than 24 hour notice. Our office reserves the right to pursue any other remedy by law. Delinquent Accounts Account balances are due within 15 days of statement date. Delinquent accounts may be pursued through third party collection agencies at the account holder s responsibility at a charge of 8% interest. Authorizations I affirm that the information given is correct to the best of my knowledge. It will be held in confidence and it is my responsibility to inform to office in any changes of address, employment information, insurance information, and medical status. I authorize the release of all information necessary to secure benefits otherwise payable to me. I assign directly to Kelli Hinds Family Dentistry all insurance payments otherwise payable to me. I understand that I am responsible for the full balance, including but not limited to third party collection fees. I authorize the dental staff to perform all necessary dental treatment needed. Like any treatment of the body, there are certain risks, benefits, limitations, and alternatives to treatment and no guarantee of the outcomes or cures will be given. I understand it is difficult to predict any symptoms, if any, I may encounter as a result of treatment. I affirm that my signature represents my agreement to all of the above terms. Signature of Patient, Parent or Guardian:

2 TIME 1:36 PM Kelli Hinds Family Dentistry DATE 5/29/2013 MEDICAL HISTORY PATIENT NAME Birth Date 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. Are you under a physician's care now? If yes, please explain: Have you ever been hospitalized or had a major operation? If yes, please explain: Have you ever had a serious head or neck injury? If yes, please explain: Are you taking any medications, pills, or drugs? Do you take, or have you taken, Phen-Fen or Redux? If yes, please explain: Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Are you on a special diet? Do you use tobacco? Do you use controlled substances? Women: Are you Pregnant/Trying to get pregnant? Taking oral contraceptives? Nursing? Are you allergic to any of the following? Aspirin Penicillin Codeine Local Anesthetics Acrylic Other If yes, please explain: Metal Latex Sulfa drugs Do you have, or have you had, any of the following? AIDS/HIV Positive Alzheimer's Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Breathing Problem Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pacemaker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice Have you ever had any serious illness not listed above? If yes, please explain: Comments: 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 patient's) health. It is my responsibility to inform the dental office of any changes in medical status. SIGNATURE OF PATIENT, PARENT, or GUARDIAN DATE

3 Missed Appointment / Show Policy The definition of a missed appointment is when a patient does not show up for a scheduled appointment without sufficient notification, or any notification at all. In other words, if we do not have a reasonable amount of time to fill that empty slot caused by your failure to keep your scheduled appointment; it will be considered a failed or missed appointment. We ask for notification of 48 hours in advance (weekend day not counted) if you know that you will not be able to make your appointment. We are very understanding about certain situations. Some notification is always better than none, and we are usually willing to take that into consideration. If a patient is at least five minutes late to any appointment, it will be considered a missed appointment and the appropriate action will be taken. We do have the right to charge for missed appointments and our policy is as follows: For established patients: 1. First missed appointment with a chair time less than 1.5 hours will not be charged. All appointments over 2 hours will require a deposit to reserve your spot and will be forfeited if you fail to cancel with in the required amount of time. 2. Second missed appointment within a period of one year - $50.00 charge 3. Third missed appointment within a period of one year Discharged from practice. 4. Exception: Missed appointments scheduled for the same day as a work-in will ALWAYS be charged a $50 fee. For new patients: 1. further appointments will be allowed after cancelling less than 48hrs We provide confirmation calls, text, and s prior to your appointment as a reminder. This is a courtesy and does not release you from your appointment obligation if we are unable to reach you to confirm your appointment. We would sincerely like for everyone to understand that missed appointments without notification are extremely unfavorable to our practice. With healthcare the way it is today, it is difficult to maintain the standards of quality that we demand our dentist and staff when our schedules are disrupted. It also interferes with other patients that are waiting for an appointment. All we ask is for a phone call to let us know that you cannot make your appointment. Patient Signature: Date:

4 Kelli Hinds Family Dentistry, P.C. This tice describes how your health information may be used and disclosed and how you can get access to this information. Please review it carefully. The privacy of your health information is important to us. Our Legal Duty Federal and state laws require us to maintain the privacy of your health information. We are also required to provide this tice about our office s privacy practices, our legal duties, and your rights regarding your health information. We are required to follow the practices that are outlined in this tice while it is in effect. This tice takes effect the date of your first appointment with us, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this tice at any time, provided such changes are permitted by applicable law. We reserve the right to make changes in our privacy practices and the new terms of our tice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this tice and make the new tice available upon request. For more information about our privacy practices or additional copies of this tice, please contact us (contact information below). USES AND DISCLOSURES OF HEALTH INFORMATION: We use and disclose health information about you for treatment, payment, and healthcare operations. For example: Treatment: We disclose medical information to our employees and others who are involved in providing the care you need. We may use or disclose your health information to another dentist or other healthcare provider providing treatment which we do not provide. We may also share your health information with a pharmacist in order to provide you with a prescription, or with a laboratory that performs tests or fabricates dental prostheses or orthodontic appliances. Payment: We may use and disclose your health information to obtain payment for services we provide you; unless you request that we restrict such disclosure to your health plan when you have paid out of pocket and in full for services rendered. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include, but are not limited to, quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it is in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this tice. To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this tice. You have the right to request restrictions on disclosure to family members, other relatives, close personal friends, or any other person identified by you. Unsecured We will not send you unsecured s pertaining to your health information without your prior authorization. If you do authorize communications via unsecured , you have the right to revoke the authorization at any time. Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and our experience with NOTICE OF PRIVACY PRACTICES 1 This resource is provided by the CDA Practice Support Center. Visit the website at cdacompass.com or call

5 common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, X rays, or other similar forms of health information. Marketing Health Related Services: We may contact you about products or services related to your treatment, case management or care coordination, or to propose other treatments or health related benefits and services in which you may be interested. We may also encourage you to purchase a product or service when you visit our office. If you are currently an enrollee of a dental plan, we may receive payment for communications to you in relation to our provision, coordination, or management of your dental care, including our coordination or management of your health care with a third party, our consultation with other health care providers relating to your care, or if we refer you for health care. We will not otherwise use or disclose your health information for marketing purposes without you written authorization. We will disclose whether we receive payments for marketing activity you have authorized. Change of Ownership: If this dental practice is sold or merged with another practice or organization, your health records will become the property of the new owner. However, you may request that copies of your health information be transferred to another dental practice. Required by Law: We may use or disclose your health information when we are required to do so by law. Public Health: We may, and are sometimes legally obligated, to disclose your health information to public health agencies for purposes related to preventing or controlling disease, injury or disability; reporting abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure. Upon reporting suspected elder or dependent adult abuse or domestic violence, we will promptly inform you or your personal representative unless we believe the notification would place you at risk of harm or would require informing a personal representative we believe is responsible for the abuse or harm. Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. 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 institutions or law enforcement officials having lawful custody of protected health information of inmates or patients under certain circumstances. Appointment Reminders: We may contact you to provide you with appointment reminders via voic , postcards, or letters. We may also leave a message with the person answering the phone if you are not available. Sign In Sheet and Announcement: Upon arriving at our office, we may use and disclose medical information about you by asking that you sign an intake sheet at our front desk. We may also announce your name when we are ready to see you. PATIENT RIGHTS Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by contacting our office. We will charge you a reasonable cost based fee for expenses such as copies and staff time. You may also request access by sending us a letter. If you request copies, there may be a charge for time spent. If you request an alternate format, we will charge a cost based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us for a full explanation of our fee structure. Disclosure Accounting: You have a right to receive a list of instances in which we disclosed your health information for purposes other than treatment, payment, healthcare operations and certain other activities for the last six years. If you request this accounting more than once in a 12 month period, we may charge you a reasonable cost based fee for responding to these additional requests. This resource is provided by the CDA Practice Support Center. Visit the website at cdacompass.com or call California Dental Association

6 Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in emergency). In the event you pay out of pocket and in full for services rendered, you may request that we not share your health information with your health plan. We must agree to this request. Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. Breach tification: In the event your unsecured protected health information is breached, we will notify you as required by law. In some situations, you may be notified by our business associates. Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended). We may deny your request under certain circumstances. Questions and Complaints: If you want more information about our privacy practices or have questions or concerns, please contact us at: Contact: Dr. Kelli Hinds Telephone: (317) Fax: (317) E mail: Info@kellihindsfamilydentistry.com Address: 1480 W. Southport Road Suite A Indianapolis, Indiana If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may send a written complaint to our office or to the U.S. Department of Health and Human Services, Office of Civil Rights. We will not retaliate against you for filing a complaint. This resource is provided by the CDA Practice Support Center. Visit the website at cdacompass.com or call California Dental Association

7 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES **You May Refuse to Sign This Acknowledgement** I, (Print Name) have received a copy of Kelli Hinds Family Dentistry s tice of Privacy Practices. Patient Signature: (Signature) If this Acknowledgement is signed by a personal representative on behalf of the patient, complete the following: Personal Representative's name: Relationship to Patient: For Program Use Only We attempted to obtain written acknowledgement of receipt of our tice of Privacy Practices, but acknowledgement could not be obtained because: 0 Individual refused to sign 0 Communications barriers prohibited obtaining the acknowledgement 0 An emergency situation prevented us from obtaining acknowledgement 0 Other (Please Specify)

8 AUTHORIZATION TO RELEASE INFORMATION TO FAMILY MEMBERS Many of our patients allow family members such as their spouse, parents or others to call and request dental or billing information. Under the requirements of HIPAA we are not allowed to give this information to anyone without the patient s consent. If you wish to have your dental or billing information released to family members you must sign this form. Signing this form will only give consent to release this information to the family members indicated below. This consent form will not allow Kelli Hinds Family Dentistry to release any other information to these family members. You have the right to revoke this consent in writing. I authorize/allow Kelli Hinds Family Dentistry to release my dental and/or billing information to the following individuals: 1. Relation to Patient: 2. Relation to Patient: 3. Relation to Patient: Patient Name Patient Signature: Date: AUTHORIZATION TO LEAVE MESSAGES WITH HOUSEHOLD MEMBERS/ANSWERING MACHINE: Occasionally it is necessary for the staff of Kelli Hinds Family Dentistry to leave messages for patients. The purposes of these messages is to remind patients that they have an appointment, to notify the patient that the dental staff would like to discuss or schedule dental appointments, or to ask a patient to call regarding an issue or concern. At no time will a representative of Kelli Hinds Family Dentistry discuss your dental condition without your consent. The purpose of this consent is to leave messages with members of your household or on your answering machine. You have the right to revoke this consent in writing. Patient Name: Patient Signature: Date:

9 We now have the ability to and/or text you, reminding you of your appointments. If you would like to receive this feature in the future, please read the consent below and sign. Consent to and/or Text Message for Appointment Reminders and Other Healthcare Communications: Patients in our practice may be contacted via and/or text messaging to remind you of an appointment, to obtain feedback on your experience with our healthcare team, and to provide general health reminders/information. I consent to receiving appointment reminders and other healthcare communications/information at that and/or text from Kelli Hinds Family Dentistry (Patient initials) I consent to receive text messages from the practice at my cell phone and any number forwarded or transferred to that number. The cell phone number that I authorize to receive text messages for appointment reminders, feedback, and general health reminders/information is ( ) - Carrier: (Patient initials) I consent to s, to receive communications as stated above. The that I authorize to receive messages for appointment reminders and general health reminders/feedback/information is. I understand that this request to receive s and/or text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing. Patients Signature: Date: Staff Signature: Date: