Patient Registration Montgomery Dental Arts

Transcription

1 Patient Registration Montgomery Dental Arts Patient s First Name: Middle: Last: Preferred Name: of Birth: Patient is covered by dental insurance: / Patient is the person responsible for payment: / Address: Apt: City: State: Zip: Home Ph.: Work Ph. Ext. Cell: Sex: M / F Marital Status: Married / Single / Divorced / Separated / Widowed / Partnered / Minor Social Security Number: Driver s License Number: I would like to receive correspondence via / Text: / Employment Status: Full Time / Part Time / Retired Student Status: Full Time / Part-Time Employer: School: Emergency Contact Name: Relationship to Patient: Emergency Contact Phone Number: 2nd Contact Number: Who can we thank for referring you to our office? If the Patient is not responsible for payment, please complete this section: Responsible Party First Name: MI: Last: Preferred Name: of Birth: Address: Apt: City: State: Zip: Home Ph.: Work Ph. Ext. Cell: Social Security Number: Driver s License Number: I would like to receive correspondence via / Text: / If the Patient has Dental Insurance, please complete this section: Policy Holder s Name: Patient s Relationship to the Policy Holder: Policy Holder s SSN: Policy Holder s Birth : Employer: Employer s Address: Insurance Company: Group Number: Insurance Company Address: If the Patient has Secondary Dental Insurance, please complete this section: Policy Holder s Name: Patient s Relationship to the Policy Holder: Policy Holder s SSN: Policy Holder s Birth : Employer: Employer s Address: Insurance Company: Group Number: Insurance Company Address:

2 MONTGOMERY DENTAL ARTS Dental History Reasons for today s visit: of last dental care: of last dental xrays: Former Dentist: Address: Would you like for your records to be sent to our office? / Have you had a negative experience with dental treatment at any point in the past? / If, please explain: Do you grind your teeth or has anyone ever told you that you grind your teeth? / If, please explain: Do you fall asleep easily through the day, are overtired or do not feel rested? / If, please explain: Do you have any specific goals for your future dental treatment (for example: interest in implants, veneers, etc.) / Please explain: Medical History 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 a medication that you are taking could have an important relationship with the dentistry you will receive. Thank you for answering the following questions: Primary Physician: Phone: Approximate date of last visit: Are you under the care of a medical specialist? / If, please list: Specialist Name: Phone: Specialist Name: Phone: Have you ever had an operation? / If, please list any complications such as bleeding, infection, poor healing, etc.: Have you ever been sedated for a medical procedure? / If, please list any complications related to your sedation: Can you easily move your head and neck in all directions? / If, please explain: Do you use tobacco? / If, what type? How long? Interested in quitting? / Do you use controlled substances? / What type? Women- Are you: Pregnant/trying to get pregnant? / If yes, when is your due date? Taking oral contraceptives? / Nursing? / Have you ever taken any medications such as Fosamax, Boniva, Actonel or any other medications containing bisphosphonates for a bone condition? / If, was the medication a ( ) Pill/tablet ( ) IV/injection? How many years did you receive the medication? Name of medication(s) : Are you allergic to any of the following? Drug Allergies Aspirin NSAIDS Penicillin Codeine Local Anesthetics Acrylic Metal Latex Sulfa Drugs Other If you circled any of the above, what were your symptoms when you had a reaction?

3 MONTGOMERY DENTAL ARTS Medication List If you are taking any medications, please complete this section. Please include supplements or over-the-counter medications. Medication Dose When I take it/how often Other Instructions I am not currently taking any medications. 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 Pace Maker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse 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 MONTGOMERY DENTAL ARTS DR. CARL SHAMBURGER DR. DOMINIQUE ASKEW SHAMBURGER Chantilly Parkway, Montgomery, Alabama Phone Fax Medical History (p.2)

4 PATIENT AGREEMENT We are committed to providing you with the best possible care. understanding of our financial and scheduling policies. In order to achieve these goals, we ask for your assistance and Financial Policy Payment for services rendered is due and payable at the time of treatment. We accept Cash, Checks, Visa, MasterCard, American Express and Discover. We are an authorized provider for CareCredit and Lending Club patient financing, which may afford you the opportunity to make monthly payments for your treatment. Third party financing offers low interest and long term payment plans to qualified applicants. Please inquire if you are interested in applying. Minor Children: The parent or guardian that brings a minor child in for treatment in our practice is responsible for payment for services. Administrative Fees and Interest: There is a $30 service charge for returned checks. Account balances that are 30 days or more past due are subject to 1½% monthly interest (18% annual percentage rate (APR)). Dental Insurance: Dental insurance amounts are estimated coverage only; the estimated patient share of fees is required at the time of service. The patient/responsible guardian is responsible for amounts not covered by insurance or claims not paid within 60 days from date of service. Balances owed are subject to interest and collection practices of this office. Secondary Dental Insurance Coverage: While we do file claims with secondary insurance plans, due to co-insurance limitations, any financial arrangements made in our practice will be based on estimated primary coverage only. If you have any questions about the above information or any uncertainty regarding insurance coverage, please don t hesitate to ask us. We are here to help! Appointment Policy: We do not double-book appointments in our office and request 2 business days notice for all cancellations of appointments. Broken appointments or late cancellations of appointments with less than 24 hours notice are subject to a $50 fee. We ask for your cooperation in managing your appointments so that we can maintain the greatest possible access to care for each of our valued patients. Acknowledgement: I have been informed of Montgomery Dental Arts financial and appointment policies. I agree to be responsible for all fees incurred during the course of my treatment. I hereby authorize payment of the insurance benefits otherwise payable to me directly to Montgomery Dental Arts. Agreement to Pay: I, the undersigned, accept the fee charged as a legal and lawful debt and agree to pay said fee, including any/all collection agency fees, (33.33%), attorney fees and/or court costs, if such be necessary. Signature Express Prior Consent to Contact Consumer by Cell Phone: You agree, in order for us to service your account or to collect monies you may owe, Montgomery Dental Arts and/or our agents may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or s, using any address you provide to use. Methods of contact may include using pre-recorded/artificial voice messages and/or use of automatic dialing device, as applicable. I/We have read this disclosure and agree that Montgomery Dental Arts, its employees and/or agents may contact me/us as described above. Signature of Patient or Responsible Party Chantilly Parkway, Montgomery, Alabama Phone

5 Montgomery Dental Arts ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES * You may refuse to sign this acknowledgement* Name: DOB: Social Security #: I authorize the following for reminders of my appointments: Open Correspondence Messages at work Wk# Messages on Cell Cell# Text Messages Cell# Messages at home Hm# Postcard Address I authorize person(s) to whom my medical and dental information may be released: Name Relationship Contact# Name Relationship Contact# Name Relationship Contact# I have read the consent of this authorization form and I agree with all statements made. I understand that, by signing this form, I am confirming my authorization fo use and/or disclosure of the protected health information described in this form with the people and/organizations named in this form. X Sigature of Patient (Guardian) I acknowledge receipt of the tice of Privacy Practices form which details how Protected Health Information may be used and disclosed, and how I may access that information. X Sigature of Patient (Guardian)

6 Most dental insurance plans are a business arrangement between an insurance company and an employer. It is important to remember that reimbursement and benefit levels are based on carrier and employer business decisions and not on an individual s need for treatment. Dental plans are set up to pay only a portion of your dental health expenses. Dental plan maximum benefits average $1,000 to $1,500 per year. These amounts have not changed since the 1980's, while the cost of living has increased dramatically in comparison. Most dental plans exclude coverage for cosmetic treatments such as teeth whitening or veneers. Many have age or frequency limitations such as fluoride treatments or dental sealants. Some dental plans do not offer coverage for pre-existing conditions such as missing teeth. This type of plan would not cover prosthetic tooth replacement procedures such as bridges, partial dentures, full dentures or dental implants. Most dental plans also have waiting periods for replacement of existing crowns, bridges or dentures. Many insurance plans will apply alternate benefits towards a service, such as paying for silver fillings rather than tooth-colored fillings, or not covering major restorative services, such as crowns, inlays or onlays and paying for regular fillings instead. Some dental plans may use the terms "usual, customary and reasonable" (UCR) to determine insurance benefits. This term applies to fee research methods used by dental insurance carriers to set reimbursement levels across the country. The criteria upon which this research is based, such as region, time intervals, type of dentist, etc. can vary greatly from one insurance carrier to another. Our Commitment is to Your Health, regardless of insurance status. Acknowledged: I have read these Facts About Dental Insurance and I understand that any insurance reimbursement amount presented to me regarding my dental insurance coverage is an estimate only and not a guarantee of payment. I understand that I will be given a copy of my treatment plan with American Dental Association (ADA) codes so that I may call my insurance company for details about my plan. Patient/Guarantor Signature Chantilly Parkway, Montgomery, Alabama Phone