Sinh Ta, D.D.S. Ela Jamiolkowski, D.M.D. Leslie Yuan Gazdeck, D.D.S.

Transcription

1 Ela Jamilkwski, D.M.D. Leslie Yuan Gazdeck, D.D.S. 1. Patient Infrmatin: Patient Name: Nickname: Child's Age: Birth date SSN# Hme Address: 2. Persn Respnsible fr Accunt: Name: DOB: Relatinship t Child: Address: Hme phne # Cell phne # Address: Name f child's parents Hw did yu hear abut us 3. Primary Dental Insurance: Insurance Cmpany Name: Insurance Cmpany Address: Grup # Plicy Owner's Emplyer Plicy Owner's Name: Plicy Owner's DOB Relatinship t Patient: Scial Security # 4. Dental Histry: What is the reasn fr tday s visit? When was yur child's last visit t a dentist? Have past dental experiences been satisfactry? Has yur child had any f the fllwing? (Please check all that apply t yur child) Bleeding Gum Brken Filling Chrnic Bad Breath Decayed teeth Grinding Injury t teeth Lip Sucking/ Nail Biting Nursing/Bttle habit Lse teeth Painful r Lcking jaw Sensitivity t sweet, ht,cld & biting Sres r swelling in muth Thumb & finger sucking

2 Ela Jamilkwski, D.M.D. Leslie Yuan Gazdeck, D.D.S. 5. Medical Histry: Des yur child have r have a histry f the fllwing? (Please circle all that apply t yur child) ADHD Abnrmal bleeding, Heart murmur Autism/ Spectrum prlnged healing, Heart disease Disrder bruising easily (describe) Anemia, hemphilia, Cancer Hepatitis/liver ther bld disrders Develpmental Delays diseases/jaundice Asthma, Cystic Diabetes HIV/ Sexually Fibrsis/Respiratry Epilepsy/seizures Transmitted Disease disease Glaucma/eye Kidney disease Autimmune disease disrders Sickle Cell Disease/Trait Skin, muscle, jint disease Speech/Hearing Impairment Thyrid disease Tuberculsis Ulcer/digestive disrders Please list ANY medical cnditins nt listed that the child has had: Is yur child currently under the care f a physician? Yes N Physician Tel # Date f last physical exam: Please list all medicatins yur child is currently taking as well as ver-the-cunter medicatins, herbal remedies, vitamins, hmepathic remedies: Allergies/reactins t medicatins, r ther allergies? Please describe any impending r past peratins, recent injuries r ther infrmatin the dentist shuld be aware f: Which f the fllwing categries best describes yur child s learning abilities? Delayed Nrmal Advanced Hw d yu think yur child will cperate fr this appintment? Well-behaved Unsure Uncperative I understand that the infrmatin I have given is crrect t the best f my knwledge, that it will be held in the strictest f cnfidence and it is my respnsibility t infrm this ffice f any changes my child's medical status. I authrize the dental staff t perfrm any dental services they find my child may need. Patient signature Date Dentist s initials

3 Ela Jamilkwski, D.M.D. TO OUR PATIENTS AND FAMILIES Thank yu fr chsing Tribeca Nrth Dental fr yur child s dental care. We cnsider families t be an essential participant in yur child s care and wish t supprt and respect yur needs while yur child is under ur care. We want yu t understand yur rights and respnsibilities as families and patients at Tribeca Nrth Dental. Parents in the Back Yu may chse whether r nt yu accmpany yur child t the treatment rm fr his/her appintment. Althugh we are sensitive t the fact that yu may have mre than ne child and that mre than ne family member may want t participate, we ask that nly ne adult cme t the back. Our gal is t nt nly prvide the highest quality f care but als t effectively cmmunicate with yu and yur child t prvide as much dental educatin as pssible. This is very difficult if bth yu and yur child are distracted by ther siblings r when a child is trying t get the attentin f bth f their parents at the same time. Missed/Brken Appintment Plicy Due t the limited space in ur schedule and the need t prvide timely service t all f ur patients it is very imprtant that yu keep yur scheduled appintments. It is understandable that ccasinally yu may need t reschedule due t an emergency r illness. We ask that yu give us the curtesy f a 24 hur ntice s that we will have the pprtunity t use yur appinted time t prvide treatment fr thers in need. INITIALS Assignment f Benefits (AB) and Release f Infrmatin (RI) I cnsent t and authrize that payment f benefits fr healthcare related services be made t Tribeca Nrth Dental. This cnsent specifically authrizes Tribeca Nrth Dental t release Prtected Health Infrmatin (PHI) t insurers, gvernmental agencies and their agents fr billing purpses and determinatin f benefits. I assign any benefits payable fr prvider services t the prvider r rganizatin prviding the services. I understand that there is n guarantee f reimbursement r payment frm any insurance cmpany r ther payer. I acknwledge full financial respnsibility fr, and agree t pay, all charges f Tribeca Nrth Dental and f prviders rendering services nt therwise paid by my health insurance r ther payer. All charges due are payable upn receipt f the bill. If payment is nt made within 60 days after receipt f bill, a delinquent charge r interest f 18.00% (1.5% mnthly ratewill be added. I agree t pay all csts f cllectin including attrney fees, cllectin fees and curt csts. The terms f this AB and RI will be until final payments are made fr all services. If and when there are any changes t my insurance plans, I will ntify Tribeca Nrth Dental staff and sign a new agreement. Insurance AT THIS OFFICE WE FOLLOW THE GUIDELINES OF THE AMERICAN ACADEMY OF PEDIATRIC DENTISTRY IN REGARD TO FREQUENCY OF X-RAYS, CLEANINGS, FLUORIDE TREATMENTS, AND RESTORATIVE CARE. AS SPECIALISTS WE CONSIDER THESE GUIDELINES TO BE THE STANDARD OF CARE (BEST TREATMENT FOR YOUR CHILD). THESE GUIDELINES ARE NOT DICTATED BY DENTAL INSURANCE AND IT IS YOUR RESPONSIBILITYTO UNDERSTAND WHETHER YOUR PARTICULAR INSURANCE PLAN WILL REIMBURSE YOU FOR THESE SERVICES. PLEASE CALL YOUR INSURANCE COMPANY WITH QUESTIONS REGARDING FREQUENCIES. Print Patient s Name Date Parent/Guardian Signature Printed Name Relatinship t patient(s)

4 Ela Jamilkwski, D.M.D. Practice Terminlgy In rder t imprve the chances f yur child having a psitive experience in ur ffice, we are selective in ur use f wrds. We avid wrds that may scare children due t previus experiences. Please supprt us by nt using negative wrds that are ften used fr dental care. We appreciate yur cperatin in helping us build a gd attitude fr yur child! DON T USE Needle r sht Drill Drill n tth Pull r yank tth Decay r cavity Examinatin Tth cleaning Explrer Islite Gas r nitrus OUR EQUIVALENT Cld water squirter/ Snwman maker Tth Cleaner/ Tth tickler Clean a tth/tickle a tth Hug a tth Sugar bug/dirt Cunt teeth Tickle teeth Tth cunter Mr Fishy Magic air/ ice cream maker Parent Guidelines Yu may chse whether r nt yu accmpany yur child t the treatment rm fr his/her appintment. Althugh we sense that sme children d better withut parents being present, we are pen t having yu with yur child. If yu chse t be present, we suggest the fllwing guidelines t imprve chances f a psitive utcme. Allw US t prepare yur child Be supprtive f the practice terminlgy Please be a silent bserver supprt yur child with tuch. This allw us t maintain cmmunicatin with yur child Children will nrmally listen t their parent rather than us and may nt hear ur guidance Yu may give incrrect r misleading infrmatin If asked t leave, be ready t immediately walk away Many children will try t cntrl the situatin Acting ut is nrmal, but unacceptable during fillings This is intended t shrt circuit the cntrl attempt We will cntinue t supprt yur child at all times We may at time use 'vice cntrl' in trying t cntrl a situatin. This may mean that we will raise ur vice and speak in a stern tne. Please understand this is ne way in trying t cntrl yur child's behavir and if it des nt have psitive results we will discntinue its use. These are very imprtant ways that yu can actively help in the success f yur child s visit. We are cnfident that all will g well and hpe these guidelines will help prepare yu with cnfidence fr the upcming appintment. Please let us knw if yu have any cncerns/questins r cmments! We wuld like t further speak with yu n any tpic! Print Patient s Name Date Parent/Guardian Signature Printed Name Relatinship t patient(s)

5 Ela Jamilkwski, D.M.D. NOTICE OF PRIVACY PRACTICES Disclsure Accunting: Yu have the right t receive a list f instances in which we r ur business assciates disclsed yur health infrmatin ver the last 6 years (but nt befre April 14, 2003). That list will nt include disclsures fr treatment, payment, healthcare peratins, as authrized by yu, and fr certain ther activities. If yu request this accunting mre than nce in a 12-mnth perid, we may charge yu a reasnable, cst-based fee fr respnding t these additinal requests. Cntact us using the infrmatin listed at the tp f this ntice fr mre infrmatin abut fees. 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). Any agreement we may make t a request fr additinal restrictins must be in writing signed by a persn authrized t make such an agreement n ur behalf. Yur request is nt binding unless ur agreement is in writing. 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 request in writing. Yu must specify in yur request the alternative means r lcatin, and prvide satisfactry explanatin hw yu will handle payment 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 it must explain why we shuld amend the infrmatin. We may deny yur request under certain circumstances. QUESTIONS AND COMPLAINTS If yu want mre infrmatin abut ur privacy practices r have questins r cncerns, please cntact us using the infrmatin listed at the tp f this ntice. If yu believe that: We may have vilated yu privacy rights, We made a decisin abut access t yu health infrmatin incrrectly, Our respnse t a request yu made t amend r restrict the use r disclsure f yur health infrmatin was incrrect, r We shuld cmmunicate with yu by alternative means r at alternative lcatins, Yu may cntact us using the infrmatin listed at the tp 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 the U.S. Department f Health and Human Services. I have read and understand the abve Patient Rights t Privacy Infrmatin. Signature f Patient (Or Parent/Guardian if Child) Date

6 Brken Appintment Plicy Sinh Ta, D.D.S. Ela Jamilkwski, D.M.D. Our ffice values yur time and takes great effrt t stay n schedule. When yu reserve a time with us, we request yu make every attempt t make yur appintment, as it is set aside specifically fr yu. We have a 2-BUSINESS DAY cancellatin plicy. If yu need t change r reschedule yur reserved time with us, please give us at least a 2-BUSINESS DAY ntice s we will be able t fill this time with thers waiting fr treatment. If yu cancel, fail t shw fr yur cnfirmed appintment, r yu arrive excessively late and treatment cannt be cmpleted as planned, we must charge yu a Brken Appintment Fee f $100. We understand that unfreseen circumstances arise, s as a curtesy t ur patients, we d allw ne unexpected cancellatin withut ntice r excessively late arrival. Other than this exceptin, we will exercise ur right t charge the abve Brken Appintment Fee. We appreciate yur cperatin and understanding. Signature f Patient r Guarantr Date IT IS YOUR RESPONSIBLITY TO PAY ANY DEDUCTIBLE, AS WELL AS ANY OTHER BALANCE NOT PAID BY YOUR INSURANCE ALONG WITH ANY FEE'S DUE TO CANCELED APOINTMENTS. I have read and understand the abve. I am aware that my card is being placed n file but will nt be charged unless I have missed an appintment withut a cancelatin ntice Patient Name: Card Hlder Name: CVV: Acct Number: Acct Type: Exp Date: Signature: Date: Zip