H&M Family Dentistry New Patient Information page

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1 H&M Family Dentistry New Patient Information page Personal Information Patient Name Address City State Zip Home Phone Work Phone Cell Phone Date of Birth Social Security Number Sex M F Employer Occupation Marital Status (Please circle one): Minor Single Married Divorced Widowed Separated Spouse/Parent or Guardian Name Phone Person to Contact in Case of Emergency _ Phone **How did you hear about our office? Physician Information Name of Physician Phone Date of Last Visit Reason Do You Require A Premedication Before Any Dental Treatment? YES NO If so, What? Responsible Party Information (Who is in charge of paying your bill?) Name of Responsible Party Relationship to Patient Address Phone Date of Birth Social Security Number Employer Work Phone Is this person currently a patient at our office? Yes No Insurance Information Name of Insured Relationship to Patient Date of Birth Social Security Number Employer _ Phone Address City State Zip Code Insurance Company _ Group # Policy # Medicaid # Insurance Address City State Zip Secondary Insurance Information Name of Insured Relationship to Patient Date of Birth Social Security Number Employer _ Phone Address City State Zip Code Insurance Company _ Group # Policy # Medicaid # Insurance Address City State Zip I hereby understand that the information I have provided is the accurate to the best of my knowledge. If there are any changes to my information, I will inform H & M FAMILY DENTISTRY and update my account. I consent to the practice contacting me by and/or phone text messages for the purpose of health promotion, practice news, general follow-ups and appointment reminders. Patient Signature: Date:

2 H&M Family Dentisry Notice of Privacy Practices for Protected Health Information 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! The office/hospital is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination, and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services. Examples of Uses of Your Health Information for Treatment Purposes are: A nurse obtains treatment information about you and records it in a health record. During the course of your treatment, the physician determines he/she will need to consult with another specialist in the area. He/she will share the information with such specialist and obtain his/her input. [Note: If you intend to disclose/use PHI for appointment reminders, treatment alternatives, or health-related benefits/services, include an example of such uses here.] Example of Use of Your Health Information for Payment Purposes: We submit requests for payment to your health insurance company. The health insurance company (or other business associate helping us obtain payment) requests information from us regarding medical care given. We will provide information to them about you and the care given. Example of Use of Your Information for Health Care Operations: We obtain services from our insurers or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guideline development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services. Your Health Information Rights The health and billing records we maintain are the physical property of the office/hospital. The information in it, however, belongs to you. You have a right to: Request a restriction on certain uses and disclosures of your health information by delivering the request to our office/hospital -- we are not required to grant the request, but we will comply with any request granted; Obtain a paper copy of the current Notice of Privacy Practices for Protected Health Information ("Notice") by making a request at our office/hospital; Request that you be allowed to inspect and copy your health record and billing record you may exercise this right by delivering the request to our office/hospital; Appeal a denial of access to your protected health information, except in certain circumstances; Request that your health care record be amended to correct incomplete or incorrect information by delivering a request to our office/hospital. We may deny your request if you ask us to amend information that: Was not created by us, unless the person or entity that created the information is no longer available to make the amendment; Is not part of the health information kept by or for the office/hospital Is not part of the information that you would be permitted to inspect and copy; or, Is accurate and complete. If your request is denied, you will be informed of the reason for the denial and will have an opportunity to submit a statement of disagreement to be maintained with your records; Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office/hospital; Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a request to our office/hospital. An accounting will not include uses and disclosures of information for treatment, payment, or operations; disclosures or uses made to you or made at your request; uses or disclosures made pursuant to an authorization signed by you; uses or disclosures made in a facility directory or to family members or friends relevant to that person's involvement in your care or in payment for such care; or, uses or disclosures to notify family or others responsible for your care of your location, condition, or your death. Revoke authorizations that you made previously to use or disclose information by delivering a written revocation to our office/hospital, except to the extent information or action has already been taken. If you want to exercise any of the above rights, please contact Our front office manager Christina Bates in person or in writing, during regular, business hours. [She/He will inform you of the steps that need to be taken to exercise your rights. Our Responsibilities The office/hospital is required to: Maintain the privacy of your health information as required by law Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you; Abide by the terms of this Notice; Notify you if we cannot accommodate a requested restriction or request; and, Accommodate your reasonable requests regarding methods to communicate health information with you. We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our "Notice" or by visiting our office and picking up a copy. To Request Information or File a Complaint If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact. Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to. You may also file a complaint by mailing it or ing it to the Secretary of Health and Human Services, whose street address and address is: Office for Civil Rights - U.S. Department of Health and Human Services Independence Avenue S.W. - Room 509F, HHH Building - Washington, D.C We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the office/hospital. We cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.

3 H&M Family Dentistry 2711 South Parker Road Aurora, CO Name of Patient (please print) Date of Birth Acknowledgment of Notice of Privacy Practices I hereby acknowledge that I received H&M Family Dentistry Notice of Privacy Practices. Patient Signature: Date: Documentation of Good Faith Efforts To obtain patient s acknowledgment that they received provider s Notice of Privacy Practices (For use when acknowledgment cannot be obtained from the patient.) The patient presented to the office/hospital and was provided with a copy of Covered Entity's Notice of Privacy Practices. A good faith effort was made to obtain from the patient a written acknowledgment of his/her receipt of the Notice. However, such acknowledgement was not obtained because: Patient refused to sign. Patient was unable to sign or initial because: The patient had a medical emergency, and an attempt to obtain the acknowledgment will be made at the next available opportunity. Other reason (describe below): FOR OFFICE USE ONLY: Signature of Employee Completing Form Date [Note: Providers are required to make good faith efforts to obtain acknowledgement that each patient has received their Notice of Privacy Practices. Should the individual refuse to acknowledge receipt of provider s Notice of Privacy Practices, the provider should document the Good Faith Efforts taken to obtain such acknowledgement. The regulation does not specific how those Good Faith Efforts should be documented. This example form is meant to serve as an example of one way that a provider could satisfy this requirement.]

4 H & M Family Dentistry General Dentistry Informed Consent for Services WORK TO BE DONE I understand that I may be having the following work done: Exam, X-rays, Prophy/Cleaning, and Fillings. This consent will be valid indefinitely or unless otherwise expressed in writing by the physician or the patient. CHANGES IN TREATMENT PLAN I understand that during treatment, it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during the examination. For example, root canal therapy following routine restorative procedures. I give my permission to the dentist to make any/all changes and additions necessary. PERIODONTAL CLEANING/SCALING I understand that most common complications are pain, bleeding, tissue (gum) laceration, sensitivity to temperature or foods, swelling, ulceration (infection), tooth fracture, and/or breaking of fillings. Reactions to fluoride treatment may be nausea or vomiting. FILLINGS I understand that the most common complications are pain, sensitivity to temperature, fracture of tooth, nerve damage, damage to other teeth, occlusal (bite) discrepancies, TMJ complications, reactions to drugs and/or anesthesia. Sensitivity to hot and cold temperatures could last for a long time after the work is done. Most of the time it is just a few days. There could also be tenderness to bite and the bite may need to be adjusted. The doctor has explained to me that there are certain inherent and potential risks in ANY treatment plan or procedure. We do not expect these to occur, but there is that possibility. In this specific instance such as risks included, but not limited to the following: A. Nerve inflammation leading to hot and cold sensitivity due to deep decay or extensive restoration. B. The need for endodontic therapy (root canal therapy). C. Cracked cusp and/or fracture of the tooth or filling. D. A shorter length of serviceability of the restoration with the need for more frequent replacement. E. In cases where the previous restorations (fillings) are very large, the use of cast or full coverage crowns, or bonded porcelain may be indicated. LOCAL ANESTHETIC It has been explained to me that there are certain risks to having local anesthetic or shots with a needle. They include allergic reactions, electric shock or possible death. I understand there can be numbness in my lip or tongue or chin that can last several weeks or permanent in rare cases. Further I realize that if epinephrine is used it can cause heart flutter and acute anxiety. Local anesthetic can cause drooping of the eyelid and side of the face known as Bell s Palsey effect. At the injection site there can be bruising, swelling or a hematoma. Additionally, muscle soreness can occur on or at the injection site that can last several days or more. I understand that dentistry is not an exact science and therefore reputable practitioners cannot guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment with I have requested or authorized. I hereby authorize H&M Family Dentistry, and his staff to proceed with and perform the dental procedures and treatments as had been explained to me. I understand this is only an estimate and subject to modification depending on unforeseen or undiagnosable circumstances that may arise during the course of treatment. I understand that regardless of any insurance coverage I may have, I am responsible for payment of dental fees. I agree to pay any attorney s fees, collection fees, or court costs that may be incurred to satisfy this obligation. Patient Signature: Date:

5 Office Financial Policies of H&M Family Dentistry H&M Family Dentistry would like to welcome you to our office. Our office strives to make your experience here as pleasant and as comfortable as possible. The following is our statement of financial policy, which we require all of our patients to read, understand, and sign prior to any non-emergent treatment or care. Please feel free to discuss our fees with us at any time. Before any dental treatment is started, the patient will receive an exam and/or consultation regarding any proposed treatment plan and cost. We will provide you with an estimate of insurance benefits at that time. The patient s estimated out of pocket cost will be due at the time services are rendered. Our office does accept cash, check, Money order, Visa, MasterCard and Discover. Our office also offers financing options for those who qualify through Care Credit. All returned checks are subject to a $35.00 non-sufficient funds fee. 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/co-insurance as services are rendered. Please remember that the contract is between you and your insurance company and your total balance in our office is your responsibility regardless of any estimated insurance coverage. Our office makes every effort to give you an accurate estimate of what your portion of our fees will be based on the information provided to us by your insurance company. 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 a statement. If the insurance company has not paid the balance on your account within 60 days from the date of service, the balance will become due and a statement will be sent to you for payment. Our office is contracted with several insurances, as a result there may be insurance adjustments reflected on your account. If requested, any overpayments will be refunded or the credit can remain on your account for future services. Our office will be more than happy to submit a predetermination into your insurance if requested. Please allow 4 6 weeks for the insurance to process these requests thus, delaying treatment. Patients who do not have insurance coverage, who are unable to provide us with valid insurance information or who wish to file their own insurance claims are responsible for paying at the time services are rendered. In order to reduce administrative costs, our office requires that all cancellations be made with a minimum of 48 hours notice. Appointments cancelled without more than 48 business hours notice or failed appointments (noshow), will be subject to a cancellation fee of $50 per hour depending on the length of the appointment time. Unpaid balances will be subject to a finance charge. Account aging begins the day your charges are incurred. For accounts that are 45 days past due, appropriate action will be taken to collect the past due amount, and the patient will be responsible for the following additional fees: $35 past due fee; 50% of your unpaid balance will be added to your account if it is turned over to the third party collection agency. We dislike doing this and will do so only if all other efforts to collect your unpaid balance have failed. Once the account has been turned over to an outside collection agency, any fees, court costs and attorney fees will be the patient/guarantor s sole responsibility. All future treatments will require payment in full in cash, credit card or money order only. Patients may request a copy of their records for a nominal fee of $12.00 for the first 10 pages and $0.25 for each additional page as permitted by the Patient Records Law of Colorado. Patients will be required to sign a release of records form. Once our office receives this request, the records will be sent within 10 to 12 business days. H&M Family Dentistry reserves the right to change their fees at any time without prior notice. I authorize direct payment of dental benefits otherwise payable to me directly to H&M Family Dentistry. I am financially responsible for non-covered services, co-payments, coinsurance and deductibles. I also authorize H&M Family Dentistry to release any information required for processing of the claim(s). I have been presented with the office and financial policy. I have been given the opportunity to read these policies. My signature below acknowledges that I have read, understand and agree to adhere to the financial policies outlined above. My signature below further acknowledges that my account is my sole responsibility and not dependant on insurance benefits. I have been given the opportunity to ask questions regarding the office financial policy. Patient Signature: Date Office Witness Signature: Date: