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1 Patient Infrmatin Male r Female: SS# - - DOB: / / Address: Main Phne #: ( ) - Secndary Phne # :( ) - (Circle One): Married Single Divrced Widwed Name f Spuse r Guardian: In Case f Emergency: Whm may we cntact in the case f an emergency?: Name Phne# : ( ) - Relatinship t Patient: Primary Plicyhlder Infrmatin: Name: Phne #: ( ) - Male r Female: SS# - - DOB: / / Address: Emplyer: Emplyer Phne #: ( ) - Emplyer Address: Insurance Carrier: Insurance Phne #: ( ) - Subscriber/Member ID # Grup# Authrizatin I understand and agree that, (regardless f my insurance status), I am ultimately respnsible fr the balance n my accunt fr any prfessinal services rendered. I have als read and fully understand all the infrmatin n this frm and have cmpleted the abve answers. I therefre, certify this infrmatin is true and crrect t the best f my knwledge. If any changes ccur with my health status r the abve infrmatin I will ntify. I authrize the release f any infrmatin relating t this claim. I hereby authrize payment directly t r the grup insurance benefits therwise payable t me. - Patient r Guardian
2 Medical Histry DOB: / / Date f yur last dental care exam: Are yu under a physician s care nw? YES NO Are yu currently taking any medicatins? YES NO Wmen: Are yu Pregnant? YES NO If yes, hw many mnths? Nursing? YES NO _ Taking ral cntraceptives? YES _ NO Are yu allergic t any f the fllwing? Please circle: Aspirin, Penicillin, Cdeine Darvn, Valium Percdan, Lcal Anesthetics, Erythrmycin, Nitrus Oxide, Other: Circle any if yu have r yu have had any f the fllwing: AIDS/HIV Psitive Chest Pain Heart Murmur Lupus Anemia Cld Sres Heart Pacemaker Mitral Valve Prlapse Angina Fever Blister Hepatitis A Psychiatric Care Arthritis / Gut Cngenital Heat Disrder Hepatitis B r C Recent Weight Lss Artificial Heart Valve Cnvulsins Herpes Rheumatic Fever Artificial Jint Diabetes High Bld Pressure Sinus truble Asthma Drug Addictin Hypglycemia Strke Bld Disease Epilepsy / Seizures Irregular Heartbeat Thyrid Disease Breathing Prblem Excessive Bleeding Kidney Prblem Tuberculsis Cancer Hay Fever Leukemia Tumr Chemtherapy Heart Attack / Failure Liver Disease Venereal Disease Have yu ever had a serius illness nt listed abve? YES NO T the best f my knwledge, the questin n this frm have been accurately answered. I understand that prviding incrrect infrmatin can be dangerus t my (r patient s) health. It is my respnsibility t infrm The Lp Enddntics f any changes in medical status.
3 Patient Financial Respnsibility Disclsure and Acknwledgment Thank yu fr chsing as yur dental prvider. We are cmmitted t yur treatment being successful. Yur signature n the line belw frms a legally binding agreement between and the undersigned patient (the Patient ) wh is receiving dental care, r the respnsible party fr minr patients (thse patients under 18 years f age). The Respnsible Party is the individual wh is financially respnsible fr payment f dental bills assciated with the dental services prvided by the Lp Enddntics, and is the individual indicated n the frm belw as the Respnsible Party in the space prvided. The patient, if ver the age f 18 years f age is the Respnsible Party. The fllwing is a statement f ur payment plicy. This payment plicy applies t all services prvided by The Lp Enddntics regardless f the lcatin. All charges fr services rendered are due and payable at the time f service. Fr ur Patients with Dental Insurance Benefits: The prviders f participate in mst majr dental plans and will verify eligibility and cverage fr all insurances. Our business ffice will submit a claim fr any services rendered t a patient; hwever, it is the Respnsible Party s respnsibility t pay the entire amunt f all services rendered. It is the Respnsible Party s respnsibility t prvide all necessary infrmatin and cmplete any required frms befre leaving the ffice. will nt pursue secndary insurance cverage. That is yur respnsibility as the patient. Please cntact yur insurance cmpany with any questins abut yur insurances cverage. In additin, yur insurance cmpany may be based n fees cnsidered usual and custmary that differs frm urs. We change what is usual and custmary fr ur practice. Yu are respnsible fr payment in full regardless f yur insurance cmpany s arbitrary determinatin f usual and custmary rates. Please remember that insurance is a cntract between yu and insurance cmpany. Our ffice is nt part f this cntract. Yu are respnsible fr the timely payment f yur accunt. We cannt waive c-payments, deductibles, c-insurance r nn-cvered service amunts defined as patient respnsibility under terms f ur cntract with varius health plans. Payment f c-payments and c-insurance are due at the time f the ffice visit. Any remaining balance n yur accunt after the insurance cmpany has prcessed yur clam and sent the Explanatin f Benefits is due and wing within 30 days f receiving a statement frm ur ffice. Failure t pay all unpaid balances within 30 days f receiving a statement frm ur ffice will result in a billing fee f $15 t cver the cst f a statement being sent t yu. Fr ur Patients with n Dental Insurance Benefits: If yu d nt have dental insurance, payment fr all prfessinal services is expected at the time f yur visit. Name:
4 Office Plicy Missed Appintments: Failure t give a 24-hur ntice f an appintment r nt shwing up fr an appintment will result in a charge f $100 n yur accunt. This charge cannt be billed t the insurance cmpany and will be yur respnsibility. Failure t pay a n-shw fee will be treated accrding t ur plicy n unpaid balances, with the exceptin f cllectin ntices. A 24-hur ntice is required t change a scheduled appintment. Methds f Payment: Cash, persnal check (with valid ID), Visa, MasterCard, American Express, and Care Credit. Charge backs are cnsidered theft f retail services via the act f cnversin. This ffense is handled by the lcal plice department and settled thrugh prsecutin by the state attrney s ffice. All fees assciated with prsecutin will be accepted by the undersigned. Returned Check Plicy: If a payment is made n an accunt by check and the check is returned as Nn-Sufficient Funds (NSF), Accunt Clsed (AC), r Refer t Maker (RTM), the patient r Respnsible Party will be respnsible fr the riginal check amunt in additin t a Service Charge allwed by Flrida Statute. will ntify the respnsible party by mail in the event that a check is returned and shall in such ntice prvide fifteen (15) days frm the date f the ntice fr repayment by the Respnsible Party f the face amunt f the check plus the Service Charge. If payment f the face amunt f the check plus the Service Charge is nt received by within the applicable 15-day time perid, then may return the accunt ver t a cllectin agency fr cllectin f the same. The Respnsible Party shall be respnsible fr all csts f cllectin, which shall include a cllectin fee that will be added t the utstanding balance in additin t the face amunt f the check and Service Charge. The Respnsible Party may als be subject t civil charges pursuant t the Flrida Bad Check Statute, which amng ther things, may result in the Respnsible Party being held liable fr damages which may equal t three (3) times the face amunt f the bad check, plus statutry charges permitted by law. Past Due Accunts: In the event that shuld initiate cllectin prceedings r ther legal actin t cllect an verdue accunt, the Respnsible party acknwledges and understands that has the right t and shall disclse t its utside cllectins agency all relevant persnal and accunt infrmatin necessary t cllect payment fr services radared, including any applicable Service Charges and applicable csts f cllectins. The Respnsible Party understands and acknwledges respnsibility fr all csts f cllectins, including withut limitatins Attrneys fees and csts, curt csts, and the interest shall accrue n all unpaid balances at the rate f 1 ½ % per mnth (18% per annum). Please be advised that if a balance remains unpaid, the patient may be discharged frm. We hld the right t refuse t see a patient wh has an unpaid balance. By Signing belw, yu agree t accept full respnsibility as a patient wh is receiving dental services, r as the Respnsible Party, as applicable. Yur signature belw verifies that yu have read the abve disclsures, understand yur respnsibilities, and agree t the terms set frth herein. Patient Respnsible Party : Respnsible
5 ACKNOWLEDGEMENT OF PRIVACY PRACTICE My signature cnfirms that I have been infrmed f my rights t privacy regarding my prtected health infrmatin, under the Health Insurance Prtability & Accuntability Act f 1996 (HIPPA). I understand this infrmatin can and will be used t: Prvide and crdinate my treatment amng a number f health care prviders wh may be invlved in the treatment directly and indirectly Obtain payment frm third-party payers fr my health care services Cnduct nrmal health care peratins such as quality assessment and imprvement activities I have been infrmed f my dental prvider s Ntice f Privacy Practices cntaining a mre cmplete descriptin f the uses and disclsures f my prtected health infrmatin. I have been given the right t review and receive a cpy f such Ntice f Privacy Practices. I understand that my dental prvider has the right t change the Ntice f Privacy Practices and that I may cntact this ffice at the address belw t btain a current cpy f the Ntice f Privacy Practices. I understand that I may request in writing that yu restrict hw my private infrmatin is used r disclsed t carry ut treatment, payment r health care peratins and I understand that yu are nt required t agree t my requested restrictins, but if yu d agree then yu are bund t abide by such restrictins. Relatinship t Patient: Dependent family members als cvered in this acknwledgement: ****************************************Fr Office Use Only******************************************* We were unable t btain the patient s written acknwledgement f ur Ntice f Privacy Practices due t the fllwing reasns. The patient refused t sign Cmmunicatin Barrier Emergency Situatin
STOUGHTON DENTISTRY PATIENT INFORMATION INSURANCE INFORMATION ADDITIONAL INSURANCE INFORMATION
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: Email: Preferred Cntact Methd:
Patient Information. Personal Information. Preferred name: ( ) Male ( ) Female ( ) Single ( ) Married
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Patient Infrmatin Date Child s Name Birthdate Gender M F Nickname SS# Respnsible Party Name Relatinship Address, Email address Hme Phne Cell Phne Wrk Phne Name f Schl Hbbies Whm may we thank fr referring
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PERSONAL. Guarantor Name Last First MI (Preferred)
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