ROBERT MILLER, D.D.S. PATIENT REGISTRATION

Transcription

1 ROBERT MILLER, D.D.S. PATIENT REGISTRATION Patient Name Preferred Name or Nickname Home Address Home Phone Work Phone Cell Phone Date of Birth SS # Driver s License # Patient s Employer Address Spouse s or Guardian s Name SS # Date of Birth Spouse s or Guardian s Employer SS # Date of Birth Address Employer Phone Number Extension Who can we thank for referring you? INSURANCE INFORMATION Primary Insurance Carrier Insured s Name Date of Birth Group Number ID Number Claim Address Telephone Number Secondary Insurance Carrier Insured s Name Date of Birth Group Number ID Number Claim Address Telephone Number

2 ROBERT MILLER, D.D.S. DENTAL HISTORY Patient Name: Age: What is the reason for your visit today? Date of: Last Dental Visit Last Dental Cleaning Last Full-Mouth X-Rays What was done at your last dental visit? Previous Dentist s Name Address Telephone How often do you have dental examinations? How often do you brush your teeth? How often do you floss? What other dental aids do you use (proxybrush, tongue cleaner, rubber tip stimulator, etc.)? Do you have any dental problems at this time? Yes No If yes, please describe: Are any of your teeth sensitive to: Have you ever had: Hot or cold Yes No Chronic Treatment Yes No Sweets Yes No Oral Surgery Yes No Biting or Chewing Yes No Periodontal Treatment Yes No Have you noticed any mouth odors Yes No Your teeth ground or the bite Do you frequently get cold sores adjusted Yes No blisters or any other oral lesions.. Yes No A bite plate or mouth guard Yes No A serious injury to the mouth Do your gums bleed or hurt?..... Yes No or head? Yes No Have your parents experienced If so, please describe: Gum disease or tooth loss? Yes No Have you noticed any loose teeth or change in your bite? Yes No Have you ever experienced: Does food tend to become caught Clicking or popping of the jaw.... Yes No In between your teeth Yes No Pain (joint, ear or side of the face)... Yes No If yes, where? Difficulty opening or closing your mouth? Yes No Do You: Clench or grind your teeth while Difficulty in chewing on either side. Yes No awake or asleep? Yes No Headaches, neck aches, shoulder Bite your lips or cheeks regularly?. Yes No aches Yes No Hold foreign objects with your Sore Muscles (neck, shoulder).... Yes No teeth (pencils, pins, nails, fingernails). Yes No Mouth breathe while awake or Are you satisfied with your teeth s asleep? Yes No appearance? Yes No Have tired jaws, especially in the Would you like to have whiter teeth? Yes No morning? Yes No Would you like to have straighter Smoke/Chew tobacco Yes No teeth? Yes No Drink alcoholic beverages often? Yes No Would you like to keep your teeth for the rest of your life? Yes No Do you feel nervous about dental treatment? Yes No If yes, what are your concerns? Have you ever had an upsetting dental experience? Yes No If yes, please describe: Is there anything else about having dental treatment that you would like us to know Yes No If yes, please describe:

3 ROBERT MILLER, D.D.S. MEDICAL HISTORY Patient Name: Age: Have you been under the care of a physician during the past 2 years? Yes No If yes, for what? Physician s Name Phone Address State Zip code Are you taking any medications, drugs or pills? Yes No If yes, please list names & dosages: Are you aware of having any allergic reactions to any medications or substances? Yes No If yes, please list: Indicate which of the following you have had, or presently have. Circle yes or no for each item. Chest Pain Yes No Asthma Yes No Heart (Surgery, Disease, Attack) Yes No Hay Fever Yes No Congenital Heart Defect Yes No Latex Sensitivity Yes No High Blood Pressure Yes No Allergies or Hives Yes No Heart Murmur Yes No Sinus Trouble Yes No Mitral Valve Prolapse Yes No Tumors Yes No Artificial Heart Valve Yes No Radiation Therapy Yes No Heart Pacemaker Yes No Chemotherapy Yes No Rheumatic Fever Yes No Hepatitis A, B or C Yes No Arthritis/Rheumatism Yes No Venereal Disease Yes No Cortisone Medicine Yes No Herpes (Oral or Genital) Yes No Swollen Ankles Yes No HPV (Human Papaloma Virus) Yes No Stroke Yes No AIDS Yes No Diet (Special/Restricted) Yes No HIV Positive Yes No Artificial Joints (Hips, Knees, etc) Yes No Cold Sores/Fever Blisters Yes No Kidney Trouble Yes No Blood Transfusions Yes No Ulcers Yes No Hemophilia Yes No Diabetes Yes No Sickle Cell Disease Yes No Thyroid Problems Yes No Liver Disease Yes No Glaucoma Yes No Yellow Jaundice Yes No Contact Lenses Yes No Neurological Disorders Yes No Sleep Apnea/Snoring Yes No Epilepsy or Seizures Yes No Chronic Cough Yes No Fainting or Dizzy Spells Yes No Emphysema Yes No Nervous/Anxious Yes No Tuberculosis Yes No Psychiatric/Psychological Care Yes No Do you have or have you had any disease, condition or problem no listed? Yes No If yes, please list: Women, are you: Pregnant? Yes months No Nursing? Yes No Taking Birth Control Pills? Yes No I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, which may release such information to me. I will notify Dr. Miller of any changes in my health and medications. Patient/Guardian Signature Date Medical History Reviewed by: Date

4 ROBERT MILLER, D.D.S. DENTAL INFORMATION RELEASE FORM Patient Name Patient Date of Birth Address City/State/Zip I hereby authorize the protected health information regarding the above-named person to be exchanged between: From/To: Person/Institution Address City/State/Zip This information for which I m authorizing disclosure will be used for the following purpose: My personal use Sharing with other health care providers Other (Please Specify) This authorization will expire: Date, 20. If not otherwise specified, this release will expire within 1 year of the date of the signature. Authorization for Release of Patient Health Information: Patient Name Patient Date of Birth Unless revoked, this authorization will expire 1 year from the date of signature on the authorization or from the date noted above. I understand authorizing the use or disclosure of information is voluntary. I understand that once Robert Miller DDS discloses my dental information to the recipient, Robert Miller DDS cannot guarantee that the recipient does not re-disclose my health information to a third party. The third party may not be required to abide by this authorization or applicable federal and Illinois law governing the use and disclosure of my health information. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to Robert Miller DDS s Information Manager. I understand that the revocation will not apply to information that has already been released in repose to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. I understand the Robert Miller DDS may, directly or indirectly, receive remuneration from a third party in connection with the use and disclosure of my health information. I have read and understand the terms of this authorization and I have had the opportunity to ask questions about the use and disclosure of my health information. By my signature, I hereby, knowingly and voluntarily authorize Robert Miller DDS to use or disclose my health information in the manner described above. Print Name of Patient: Signature of Patient: Date:

5 Robert Miller DDS Office and Financial Policies 113 E. Schaumburg Rd. 480 Brairgate Dr. Schaumburg, IL South Elgin, IL Welcome and thank you for choosing Robert Miller DDS for your dental care. We are committed to providing you with the highest quality dental care, in an efficient, timely and cost-effective manner. We hope that by providing you with our policies in advance we can prevent any misunderstanding or frustration at the time of your visit. Appointments: We do our best to keep on schedule, so please arrive on time. If you arrive more than 20 minutes past your appointment time you may be reschedules so that other patients are not inconvenienced. Please inform the receptionist of any demographical changes (e.g. phone number, address, , etc.) or financial changes (e.g. insurance information, etc.) Failure to notify us immediately of changes in demographical or financial information may result in denial of your dental claim(s) by your insurance provider, thus increasing your financial responsibility for any services provided by our practice. We require a 24-hour advance notice if you must cancel your appointment. For your convenience we confirm your appointment with a call 48 hours prior to your appointment. Each patient is allowed one no show/short notice cancellation without penalty. The second no show/short notice cancelation will result in a $50 charge to your account. If you have 2 no show/short notice cancellations in your file, you will also be required to secure any subsequent appointments with a credit card and any no show/short notice cancellation thereafter will be charged $100. Insurance: When making an appointment with our office, it is your responsibility to confirm with your insurance company that Dr. Robert Miller is currently under contract with your plan. As a service to you, we will bill your insurance company. While providing this service, it is extremely difficult for us to be aware of the multitude of individual requirements for each of these plans. Each plan has its own stipulations regarding the coverage of, and payment for, dental services; therefore, it is your responsibility to know your plan s benefit policies including co-payments, prior to your appointment. In order for us to bill your insurance, we must have a current copy of your dental card along with a driver s license or ID to confirm current demographic information. If this is not provided at the time of the appointment you can; reschedule, put a credit card on file or pay in full at the time of service. If you put a credit card on file, you will have 24 hours to issue the necessary insurance information before your credit card will be charged. We allow 30 days for your insurance to respond to a claim, and 60 days for them to process and/or issue payment. If your insurance does not respond or party your claim within 60 days, the full balance will become the patient/guarantor s responsibility. Your insurance coverage and benefits are a contract between you and your insurance company; therefore, all disputes must be handled by you. Dependant Insurance: Parents are responsible for confirming insurance coverage and submission requirements for all dependent children. This is especially important for dependants between the ages of 18 to 26 as each insurance policy may vary. For dependants 18 to 26 that are full time students, confirmation of student status must be provided at the time of the appointment with a copy of a student ID or transcript.

6 Payment in full is preferred at the time services are rendered: co-pays and all non-covered services are the insured/patient s financial responsibility and are due the day services are rendered. If we consent to mail you a statement, the outstanding balance is due within 10 days. A rebilling fee of $18 will be added for each additional statement that must be sent. Past due balances are required to be paid before any further services are provided by our office, unless other financial arrangements have been made with our Business Manager. Failure to pay any past due balances will result in restricted services for you and your family. Payment Plans: In certain cases, our practice will consider establishing a structures payment plan. Each case is reviewed individually to determine eligibility and is at the sole discretion of our practice to offer such privileges to patients. All payments must be received by the agreed due dates or a $10 late fee will be assessed to the account Collection and Outstanding Balances: Delinquent accounts may be placed with a collection agency and may be subject to legal action. In the event that your unpaid balance is turned over to a collection agency for recovery or legal action is warranted, collection and attorney fees; as well as, court costs will be added to your balance. Returned checks will incur a $25 service fee. Minors: The parent(s) or guardian(s) must accompany a minor for the first visit to our office. The parent(s) or guardian(s) are responsible for providing current insurance information for the minor and/or payment in full for services provided. For follow-up visits, unaccompanied minors must have a written authorization for dental treatment signed by a parent or legal guardian before treatment can be rendered. Medical Records (paper copy or electronic copy): A copy of dental records and currents x-rays will be sent upon receipt of written request. A full mouth set of x-rays over 3 years old or bitewing x-rays over 1 year old are no longer of diagnostic value. Copies of old x-rays will incur a copying fee of $4/film. I have read and understand and agree to the above office and financial policies. I hereby attest that I have given and agree to provide current demographic and insurance information and authorize release of information necessary for insurance filing and pre-certification by signing this statement. X Patient Name DOB X Signature of Patient Date

7 Robert Miller DDS HIPAA Notice of Privacy Practices 113 E. Schaumburg Rd. 480 Brairgate Dr. Schaumburg, IL South Elgin, IL THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. We understand that you medical information is personal and we are committed to protecting it, In order to provide quality care and to comply with legal requirements we create a record of the care and services that you receive. The Notice applies to all of the records of your care that we maintain, whether created by facility staff or your doctor. We are required by law to: keep your medical information private, give you this Notice of our legal duties and privacy practices with respect to your medical information, and follow the terms of the Notice that is currently in effect. Use and Disclosures of Protected Health Information: Your protected health information may be used and disclosed by your doctor, our office staff and others outside our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay tour health care bills, to support the operation of the doctor s practice, and any other use required by law. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. Payment: your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for dental care may require that your relevant protected health information be disclosed to your health plan to obtain approval for the procedure. Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your doctor s practice. These activities include, but are not limited to, quality assessment, employee review, training of dental students, licensing, fundraising, and conducting or arranging for other business activities. For examples, we may disclose your protected healthy information to staff that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary; to contact you to remind you of your appointment, and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you. We may use or disclose your protected health information in the following situations without your authorization. These situations include: public health issues as required by law, communicable diseases, health oversight, abuse or neglect, food or drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity and national security, worker s compensation, inmates, and other required uses and disclosures. Under the law, we must make disclosures to you upon your request. Under the law, we must also disclose your protected health information when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements under section

8 Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object unless required by law. You may revoke the authorization at any time, in writing, except to the extent that your physician or the health care provider s practice has taken an action in reliance on the use or disclosure indicated in the authorization. Your Rights Regarding your Medical Information: In most cases, you have the right to look at or get a copy of medical information that we use to make decisions about your care, when you submit a written request. If you request copies, we may charge a fee for the cost of copying, mailing or other related supplies. If you believe that information in your record is incorrect or incomplete, you have the right to request that we amend the records as long as the information id kept by Robert Miller DDS. You must submit your request in writing, indicating your reason for requesting the amendment. We may deny your request to amend a record if the information was not created by us; if it is not part of the medical information maintained by us; or if we determine that the record is accurate. You may appeal in writing our decision not to amend your record. You have the right to request an accounting of disclosures, outside of the permitted disclosures under treatment, payment, or health care operation. You must submit your request in writing to Dr. Miller s Manager of Health Information. In your request you must state the time period not longer that 6 years and will not include dates before April 14 th, The first list you request within a 12-month period will be free; for additional lists, you will be charged for the cost of producing each request. We will notify you of the cost involved and you may choose to withdraw or modify your request at any time before costs are incurred. The list of disclosures will be given to you in paper forms only. You have the right to request confidential communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. This request must be submitted in writing to Dr. Miller s Manager of Health Information You may request, in writing, that we not use or disclose your medical information for treatment, payment, or healthcare operation or to persons involved in your care except when specifically authorized by you, when required by law, or in an emergency. We are not legally required to accept your request. Complaints: If you are concerned that your privacy rights may have been violated, or if you disagree with a decision we made about access to your records, you may contact the Manager of Health Information at Robert Miller DDS. Finally, you may send a written complaint to 113 E. Schaumburg Rd, Schaumburg, IL, and the Secretary of the Department of Health and Human Services at: Office of Civil Rights, US Department of Health and Human Services, 233 North Michigan Ave, Suite 240, Chicago, IL You may also call at: Under no circumstance will you be penalized or retained against for filing a complaint. HIPAA ACKNOWLEDGEMENT Patient Name I acknowledge that I received the Office Privacy Policy Notice for Robert Miller DDS Patient Signature Parent/Guardian Signature In case you do not agree to sign this form, our office must indicate why you declined to do so. Reason for patient s refusal: