STOUGHTON DENTISTRY PATIENT INFORMATION INSURANCE INFORMATION ADDITIONAL INSURANCE INFORMATION

Transcription

1 PATIENT INFORMATION Patient Last Name: First: MI Preferred Name: Sex: M F Birth Date: Marital Status: Scial Security N.: Street Address: City: State: Zip: Hme Phne: Wrk: Cell: Preferred Cntact Methd: Hme Wrk Cell Whm may we thank fr referring yu t ur practice? INSURANCE INFORMATION Subscriber Last Name: First: MI Birth Date: Is Subscriber a patient? Y N Subscriber SS N.: Subscriber ID: Subscriber Street Address (if different): Subscriber s relatinship t patient: Self Spuse Child Other Emplyer s Name: Grup N.: Emplyer s Street Address: Insurance Plan Name: Subscriber ID: Insurance Street Address: Insurance Phne: Is Patient cvered by additinal dental insurance? Y N (If Yes, please cmplete additinal insurance infrmatin belw) Dependent Student Status: Name f Schl: Full Time Part Time Names f ther dependents cvered under this plan: ADDITIONAL INSURANCE INFORMATION Subscriber Last Name: First: MI Birth Date: Is Subscriber a patient? Y N Subscriber SS N.: Subscriber ID: Subscriber Street Address (if different): Subscriber s relatinship t patient: Self Spuse Child Other Emplyer s Name: Grup N.: Emplyer s Street Address: Insurance Plan Name: Subscriber ID: Insurance Street Address: Insurance Phne: Dependent Student Status: Name f Schl: Full Time Part Time Names f ther dependents cvered under this plan:

2 HEALTH HISTORY Physician s Name: Street Address: Phne: Are yu currently being treated by a physician? Y If yes, please explain: Date f last exam: Have yu been admitted t a hspital r had emergency care in the past tw years? Y If yes, please explain: Are yu currently taking any medicatins, including ral cntraceptives r aspirin? Y If yes, please list: Have yu had an allergic reactin? Y If yes, please list all allergies: Have yu ever had Btx r fillers? Y D yu r have yu used tbacc prducts? Y Fr hw lng? D yu cnsume alchlic beverages? Y Hw ften? D yu have any histry f the fllwing diseases r cnditins? Anemia Fainting Intellectual Disability Arthritis Gastrintestinal Disrders utritinal Deficiency Asthma Hearing Lss Orthpedic Prblems Autism Heart Disease Rheumatic Fever Bleeding (prlnged) Heart Murmur Transfusin f Bld Brain injury Hepatitis/Liver Disease Sclisis Cancer: Type Herpes Sickle Cell Trait/Disease Cerebral Palsy High Bld Pressure Strke Cleft Lip/Palate HIV Infectins (AIDS) Syndrme: Type Diabetes Jaundice Thyrid Cnditin Emtinal disability Lyme Disease Other Wmen: Are yu Pregnant? Y Are yu nursing? Y T the best f my knwledge, all f the preceding infrmatin is accurate. I understand that it is my respnsibility t infrm the Dctrs and staff, if in the future, I have a change in my health status, including changes in my medicatins and/r allergies. Signature: Date: Print Name:

3 DENTAL HISTORY Reasn fr tday s visit: Date f last dental visit: Were X-rays taken? Y N Frmer Dentist s Name: Street Address: City: State: Zip: Phne: Check ( ) if yu have had prblems with any f the fllwing: Bad breath Grinding Sensitivity t ht Bleeding gums Lse teeth r Sensitivity t sweets brken fillings Clicking r ppping Peridntal treatment Sensitivity when biting jaw Fd cllectin between teeth Sensitivity t cld Sres r grwths in yur muth Hw ften d yu flss? Hw ften d yu brush? Are yu happy with yur smile? Y N If n, please explain: D yu have severe anxiety abut dental treatment? Y N Have yu ever had an adverse reactin t dental treatment? Y N If yes, please explain: T the best f my knwledge, all f the preceding infrmatin is accurate. I understand that it is my respnsibility t infrm the Dctrs and staff, if in the future, I have a change in my health status, including changes in my medicatins and/r allergies. Signature: Date: Print Name:

4 CONSENT FOR TREATMENT, INSURANCE PAYMENT AUTHORIZATION AND FINANCIAL POLICY DISCLOSURE My signature belw shall serve as my infrmed cnsent t perfrm all recmmended treatment. It shall als serve as authrizatin t assign any dental benefits paid by any third-party f insurer t my prvider. If I have insurance, I agree t make a payment f my estimated c-payment at the time services are rendered. I understand that estimated c-payments are estimates nly, subject t plicy maximums, limitatins, and crdinatin f benefit rules. After 60 days frm the date f treatment any unpaid prtin f my bill fr services rendered shall be my sle and exclusive respnsibility. Patients understand that all dental services prvided are charged directly t the patient and that he r she is persnally respnsible fr payment f all balances. This ffice will help prepare insurance frms and assist in making cllectins frm insurance cmpanies; hwever, payment is ultimately the patient s sle and exclusive respnsibility shuld the insurer r third-party payer fail, refuse r therwise neglect t make payment. All cllectins frm third-parties r insurers will be credited t the patient s accunt. If I d nt have insurance, all fees fr services rendered are due n the date f service unless prir arrangements have been made in writing. This ffice reserves the right t charge a fee fr appintments missed r canceled with less than 24 hurs advance ntice. This ffice reserves the right t charge interest f APR=12% fr verdue balances. In cnsideratin fr the prfessinal services rendered t me by Stughtn Dentistry, I agree t pay the reasnable value f said services t the Dctr r his assignee, at the time services are rendered r within 15 days f billing if credit is extended. I further agree that a waiver f any breach f any time r cnditin hereunder shall nt cnstitute a waiver f any further term r cnditin and I agree t pay all csts f cllectin, including attrney s fee and expenses, incurred t cllect any unpaid fees. Signature: Date:

5 35 Park Street Stughtn, MA Phne: Fax: ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY POLICY I have received a cpy f the Ntice f Privacy Practices f Stughtn Dentistry. I hereby authrize, as indicated by my signature belw, Stughtn Dentistry t use and disclse my identifying health infrmatin in unencrypted electrnic frmat when applicable and necessary fr any clinical, financial and insurance purpse. Print Name: Address: Signature: Date: Please check yur preferred means f cmmunicatin: Yu may cntact me at my hme telephne number Yu may cntact me n my mbile telephne number Yu may cntact me n my wrk telephne number Yu may send me an at Yu may leave detailed messages n vic f abve numbers, regarding x-ray results and/r appintment needs. Please list authrized persns with whm we may discuss yur Prtected Health Infrmatin (PHI) in additin t custdial parents and legal guardians: 1. Date Added/Remved: 2. Date Added/Remved: 3. Date Added/Remved: 4. Date Added/Remved: ***Fr Office Use Only:*** We attempted t btain written acknwledgment f receipt f ur Ntice f Privacy Practices, but acknwledgment culd nt be btained because: Individual refused t sign Cmmunicatin barriers prhibited btaining the acknwledgement An emergency situatin prevented us frm btaining the acknwledgement Other (Please specify) STAFF INITIALS