Welcome to Lowcountry Family Dentistry!

Transcription

1 Welcme t Lwcuntry Family Dentistry! Patient Medical and Dental Histry Frm Please take a few minutes t carefully read ver and answer the fllwing questins t help us treat yu safely. If yu have any questins, we will be glad t assist yu. Patient Name: Birthdate: Current Address: Phne Number: Dental Histry Reasn fr tday s visit: Frmer Dentist: City: State: Date f last dental visit: Date f last dental X-rays: Please place a mark n yes r n t indicate if yu have had any f the fllwing: Bad breath Yes N Clicking r ppping f jaw Yes N Muth Breathing Yes N Bleeding gums Yes N Blisters n muth Yes N Burning sensatin n tngue Yes N Chew n ne side f muth Yes N Histry f tbacc use Yes N Clicking r ppping f jaw Yes N Jaw pain r tiredness Yes N Dry muth Yes N Fingernail biting Yes N Fd stuck between the teeth Yes N Freign bjects Yes N Grinding teeth Yes N Gums swllen r tender Yes N Lip r cheek biting Yes N Lse r brken fillings Yes N Is there anything that yu wuld like t change abut yur teeth? Medical Histry Physician s Name: Date f last visit: Please place a mark n yes r n t indicate if yu have had any f the fllwing: AIDS/HIV Yes N Epilepsy Yes N Respiratry Disease Yes N Anemia Yes N Fainting r Dizziness Yes N Rheumatic Fever Yes N Arthritis, Rheumatism Yes N Glaucma Yes N Scarlet Fever Yes N Artificial Heart Valves Yes N Headaches Yes N Shrtness f Breath Yes N Artificial Jints Yes N Heart Murmur Yes N Sinus Truble Yes N Asthma Yes N Heart Prblems Yes N Skin Rash Yes N Bacterial Endcartitis Yes N what type? Special Diet Yes N Bleeding Abnrmally Hepatitis, type Yes N Strke Yes N with extractins r surgery Yes N Herpes Yes N Swllen Feet r Ankles Yes N Bld Disease Yes N High Bld Pressure Yes N Swllen Neck Glands Yes N Cancer Yes N Jaundice Yes N Thyrid Prblems Yes N Chemical Dependancy Yes N Kidney Disease Yes N Tnsillitis Yes N Chemtherapy Yes N Liver Disease Yes N Tuberculsis Yes N Circulatry Prblems Yes N Lw Bld Pressure Yes N Tumr r grwth n head Cngenital Heart Lesins Yes N Mitral Valve Prlapse Yes N r neck Yes N Crtisne Treatments Yes N Nervus System Prblems Yes N Ulcer Yes N Cugh, persistent r bldy Yes N Pacemaker Yes N Venereal Disease Yes N Diabetes Yes N Psychiatric Care Yes N Weight Lss, unexplained Yes N Emphysema Yes N Radiatin Treatment Yes N D yu have an allergy t Aspirin Barbituates (sleeping pills) Cdeine Idine Latex Lcal Anesthetic Penicillin Sulfa Other: D yu wear cntact lenses? Yes N Wmen: Are yu pregnant? Yes N Due date: Are yu nursing? Yes N Taking Birth Cntrl Pills? Yes N Please list any medicatins yu are currently taking and what yu are taking it fr: Pharmacy: Phne: Patient's Signature: Date:

2 Date: Patient Name: Lwcuntry Family Dentistry Ashley Cvingtn, DMD & Perry W DuRant, DMD 154 Sea Island Pkwy. Beaufrt, SC Phne: (843) First MI Last Patient Infrmatin Wh is respnsible fr this accunt? Scial Security #: Relatinship t patient: Sex: Male Female Age: Insurance Cmpany: Birthdate: Grup/Plan #: Address: Member ID #: City: Subscriber s Name: State: Zip Cde: Birthdate: SS#: Relatinship t Patient: Occupatin: Emplyer/ Schl: Emplyer/Schl Address: Married Widwed Single Minr Separated Divrced Partnered Spuse s Name: Spuse s Birthdate: Spuse s Scial Security #: Spuse s Emplyer: Whm may we thank fr referring yu? Is patient cvered by secndary insurance? Yes N Secndary Insurance Cmpany: Grup #: Member #: Assignment and Release: I certify that I, and/r my dependent(s), have insurance cverage with and assign directly t Lwcuntry Family Dentistry all insurance benefits, if any, therwise payable t me fr services rendered. I understand that I am financially respnsible fr all charges whether r nt paid by insurance. I authrize the use f my signature n all insurance submissins. The abve named dentist my use my health care infrmatin and may disclse such infrmatin t the abve-named insurance cmpanies and their agents fr the purpse f btaining payment fr services and determining insurance benefits r the benefits payable fr related services. Signature f Patient r Guardian:. Please print name:. Date: Relatinship t Patient: Phne Numbers Hme: ( ) Wrk: ( ) Ext Cell: ( ) Spuse s Wrk: ( ) Hw wuld yu prefer we cntact yu? IN CASE OF EMERGENCY, PLEASE CONTACT: Name: Relatinship: Hme: Wrk: Cell:

3 Terms f Payment The fllwing is a guide t the terms f payment we accept. We are cmmitted t wrking with yu t match a payment plan t yur needs. Therefre, we ffer different ptins t ur patients which allws fr payment t be cnvenient and flexible. We are available t answer any questins yu may have. Dental Insurance Our ffice emplys a dental insurance specialist fr ur patient s cnvenience, and we will gladly assist yu with yur dental insurance plan. T help us assist yu in btaining yur maximum dental benefits, please cme prepared with the fllwing infrmatin: A current dental insurance card, the subscribers scial security number, date f birth, and a cpy f yur driver s license (if applicable). Once yur plan cverage has been verified, we will accept the assignment f benefits frm yur dental insurance prvider. Mst plans cver nly a prtin f the dental fee. As a curtesy t ur patients, we will file yur primary dental insurance fr yu, but we ask that yu pay yur deductible and the prtin we estimate yur plan will nt cver at the time f service. If yur insurance has nt paid within 60 days f treatment, yu will be billed fr the unpaid balance, and payment in full will be expected at this time. We recmmend yu becme directly invlved in cmmunicatin with yur dental insurance cmpany in rder t expedite the payment. Payment Optins We accept Visa, Discver, and MasterCard, mney rder, cash r persnal check. A fee f $35.00 will be assigned fr all returned checks. A cnvenient interest free payment plan is available thrugh ur in-ffice financial partner CareCredit fr thse wh qualify. (Please call us fr further infrmatin) A pre-authrized payment plan n yur credit card is an ptin fr thse wh qualify. Appintments In rder t allw the best pssible care fr ur patients, we reserve a specific time just fr yu. We make every effrt t see yu as scheduled. We appreciate yur prmptness and yur cnsideratin in nt changing yur scheduled time. Hwever, if yu need t change yur appintment, 24 hurs ntice is expected. This gives us the pprtunity t schedule anther patient fr treatment in yur place. A fee f $40.00 per appintment hur will incur withut 24 hurs ntice. Patient Recrds If fr any reasn it becmes necessary fr yu t btain a cpy f yur patient recrds, please nte that we charge $20.00 recrd duplicatin fee. Please allw 7 t 10 days after cmpletin f a recrds release authrizatin t receive yur recrds. Patient Agreement I understand that my insurance plicy is an agreement between myself and the insurance cmpany; therefre I am ultimately respnsible fr all the fees incurred fr my dental treatment regardless f payment r denial f my insurance claims by my insurance cmpany. I authrize insurance payment directly t Lwcuntry Family Dentistry. I authrize the release f necessary infrmatin t my insurance cmpany t determine liability fr payment and t btain reimbursement fr any claims. If this accunt is assigned t an attrney r cllectins agency, I agree t be respnsible fr nay attrney fees, cllectin fees, and curt cst incurred. Signature f Respnsible Party Date

4 Privacy Plicy NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US. OUR LEGAL DUTY We are required by applicable federal and state law t maintain the privacy f yur health infrmatin. We are als required t give yu this Ntice abut ur privacy practices, ur legal duties, and yur rights cncerning yur health infrmatin. We must fllw the privacy practices that are described in this Ntice while it is in effect. This Ntice takes effect 1/1/2003, and will remain in effect until we replace it. We reserve the right t change ur privacy practices and the terms f this Ntice at any time, prvided such changes are permitted by applicable law. We reserve the right t make the changes in ur privacy practices and the new terms f ur Ntice effective fr all health infrmatin that we maintain, including health infrmatin we created r received befre we made changes. Prir t making a significant change in ur privacy practices, we will amend this Ntice and make the new Ntice available upn request. Yu may request a cpy f ur Ntice at any time. Fr mre infrmatin abut ur privacy practices r fr additinal cpies f this Ntice, please cntact us using the infrmatin listed at the end f this Ntice. USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclse health infrmatin abut yu fr treatment, payment, and healthcare peratins. Fr example: Treatment: We may use r disclse yur health infrmatin t btain treatment infrmatin fr services we prvide t yu. Payment: We may use and disclse yur health infrmatin t btain payment fr services we prvide t yu. Healthcare Operatins: We may use and disclse yur health infrmatin in cnnectin with ur healthcare peratins. Healthcare peratins include quality assessment and imprvement activities, reviewing the cmpetence r qualificatins f healthcare prfessinals, evaluating practitiner and prvider perfrmance, cnducting training prgrams, accreditatin, certificatin, licensing r credentialing activities. Yur Authrizatin: Other than ur use f yur health infrmatin fr treatment and payment f healthcare peratins, we will nt share - withut written authrizatin - yur health infrmatin r disclse it t anyne fr any purpse. If yu prvide an authrizatin t us, yu may revke it, in writing, at any time. Yur revcatins will nt affect any use r disclsures permitted by yur authrizatin while it was in effect. Unless yu give us a written authrizatin, we cannt use r disclse yur health infrmatin fr any reasn except thse described in this Ntice. T Yur Family and Friends: We must disclse yur health infrmatin t yu, as described in the Patient Rights sectin f this Ntice. We may disclse yur health infrmatin t a family member, friend r ther persn t the extent necessary t help with yur healthcare r with payment fr yur healthcare, but nly if yu agree that we may d s.

5 Persns Invlved in Care: We may use r disclse health infrmatin t ntify, r assist in the ntificatin f (including identifying r lcating) a family member, yur persnal representative r anther persn respnsible fr yur care, f yur lcatin, yur general cnditin, r death. If yu are present, then prir t use r disclsure f yur health infrmatin, we will prvide yu with an pprtunity t bject t such uses r disclsures. In the event f yur incapacity r emergency circumstances, we will disclse health infrmatin based n a determinatin using ur prfessinal judgment disclsing nly health infrmatin that is directly relevant t the persn's invlvement in yur healthcare. We will als use ur prfessinal judgment and ur experience with cmmn practice t make reasnable inferences in yur best interest in allwing a persn t pick up filled prescriptins, medical supplies, x-rays, r ther similar frms f health infrmatin. Marketing Health-Related Services: We will nt use yur health infrmatin fr marketing cmmunicatins withut yur written authrizatin. Required by Law: We may use r disclse yur health infrmatin when we are required t d s by law. Abuse r Neglect: We may disclse yur health infrmatin t apprpriate authrities if we reasnably believe that yu are a pssible victim f abuse, neglect, dmestic vilence, r the pssible victim f ther crimes. We may disclse yur health infrmatin t the extent necessary t avert a serius threat t yur health r safety r the health r safety f thers. Natinal Security: We may disclse t military authrities the health infrmatin f Armed Frces persnnel under certain circumstances. We may disclse t authrized federal fficials health infrmatin required fr lawful intelligence, cunterintelligence, and ther natinal security activities. We may disclse t crrectinal institutins r law enfrcement fficials having lawful custdy f prtected health infrmatin f an inmate r patient under certain circumstances. Appintment Reminders: We may use r disclse yur health infrmatin t prvide yu with appintment reminders (such as vic messages, pstcards, r letters). PATIENT RIGHTS Access: Yu have the right t lk at r btain cpies f yur health infrmatin with limited exceptins. Yu may request that we prvide cpies in a frmat ther than phtcpies. We will use the frmat yu request unless we cannt practically d s. Yu must make a request in writing t btain access t yur health infrmatin. Yu may btain a frm t request access by using the cntact infrmatin listed at the end f this Ntice. We will charge yu a reasnable cst-based fee fr expenses such as cpies and staff time. Yu may als request access by sending a letter t the address at the end f this Ntice. Cntact us using the infrmatin listed at the end f this Ntice fr a full explanatin f ur fee structure. Disclsure Accunting: Yu have the right t receive a list f instances in which we r ur business assciates have disclsed yur health infrmatin fr purpses ther than treatment, payment, healthcare peratins and certain ther activities, fr the last 6 years. If yu request this accunting mre than nce in any 12-mnth perid, we may charge yu a reasnable, cstbased fee fr respnding t these additinal requests. Restrictin: Yu have the right t request that we place additinal restrictins n ur use r disclsure f yur health infrmatin. We are nt required t agree t these additinal restrictins, but if we d, we will abide by ur agreement (except in an emergency). Alternative Cmmunicatin: Yu have the right t request that we cmmunicate with yu abut yur health infrmatin by alternative means r t alternative lcatins. Yu must make yur

6 " " " request in writing. Yur request must specify the alternative means r lcatins, and prvide a satisfactry explanatin f hw payment will be handled under the alternative means r lcatin yu request. Amendment: Yu have the right t request that we amend yur health infrmatin. Yur request must be in writing and must explain why the infrmatin shuld be amended. We may deny yur request under certain circumstances. Electrnic Ntice: If yu receive this Ntice n ur Web Site r by electrnic mail ( ), yu are entitled t receive this Ntice in written frm. QUESTIONS AND COMPLAINTS If yu want mre infrmatin abut ur privacy practices r have questins r cncerns, please cntact us. If yu wuld like mre infrmatin abut ur privacy practices r have questins r cncerns, please cntact us. If yu are cncerned that we may have vilated yur privacy rights, disagree with a decisin we made abut access t yur health infrmatin r in respnse t a request yu made t amend r restrict the use f disclsure f yur health infrmatin r t have us cmmunicate with yu by alternative means r at alternative lcatins, yu may cmmunicate with us using the cntact infrmatin listed at the end f this Ntice. Yu als may submit a written cmplaint t the U.S. Department f Health and Human Services. We will prvide yu with the address t file yur cmplaint with the U.S. Department f Health and Human Services upn request. We supprt yur right t the privacy f yur health infrmatin. We will nt retaliate in any way if yu chse t file a cmplaint with us r with U.S. Department f Health and Human Services. Cntact Officer: Tdd Cvingtn " Mail: 154 Sea Island Pkwy. Beaufrt, SC United States Telephne: Fax: beaufrtdentist@gmail.cm

7 Acknwledgement f Receipt f Ntice f Privacy Practices 1,, have received a cpy f Lwcuntry Family Dentistry s Ntice f Privacy Practices. Please Print Name Signature Date Fr Office Use Only We attempted t btain written acknwledgement f receipt f ur Ntice f Privacy Practices, but acknwledgement was nt btained fr the fllwing reasn: Individual refused t sign Cmmunicatin barriers prhibited btaining the acknwledgement An emergency situatin prevented us frm btaining acknwledgement Other (Please Specify)