Personal Information Patient Registration Form Responsible Party First Name Initial Last Name Patient First Name Initial Last Name Address City State Zip Home Phone Work Cell Birthday Social Security Email Address Emergency Contact check if you would like to receive email reminders and promotions Name Relation Phone number Phone number Referral source How did you hear about us or who referred you? Employer Information of Subscriber Insurance Employers Name Phone number Address City State Zip Full time student Yes No Where Insurance Information Primary Insured Secondary Insured Subscriber Name Subscriber SSN of Birth Relationship to *Self *Spouse Subscriber Name Subscriber SSN of Birth Relationship to *Self *Spouse Subscriber *Child *Other Subscriber *Child *Other Employer Name Employer Phone Insurance Company Insurance Phone Member ID Employer Name Employer Phone Insurance Company Insurance Phone Member ID We are preferred providers with the following companies: Aetna, Assurant/DHA, Cigna, Delta Dental, Dentemax, Guardian, Humana, MetLife, and United Healthcare. Dental insurance plans do not normally provide full coverage of your dental bill. Your dental coverage is a contract between you and your insurance company, and while we will cooperate to the fullest in expediting your claim, you are ultimately responsible for your account. Your portion of the bill will be due at time of service. If your insurance has not paid within 60 days from the date from the date of service, we will look to you for prompt payment of the account. All costs for collection of the account, should collection procedures or small claims court become necessary, will be passed on to the patient and/or the responsible party. I understand that, due to any false information, I will be subject to criminal prosecution. Signature of patient (responsible party of minor)
Medical History Patient Name DOB Have you been a medical patient or in the hospital during the past two years? Have you taken any medicine or drugs during the past two years? If so what? Are you allergic to any drugs or medications? What happens when you take that medication? Have you had any excessive bleeding requiring special treatment? YES NO Check any of the following, which you have had or have at present: Heart Problems High Blood Pressure Low Blood Pressure Rheumatic Fever Artificial Joints Stroke Kidney Trouble Cancer Tuberculosis (TB) Diabetes AIDS/HIV positive Hepatitis A Hepatitis B Hepatitis C Psychiatric Treatment Osteoporosis Drug Addiction Hemophilia Cold Sores Epilepsy or Seizures Please list any disease, conditions, or problems that you had or have that are not listed. Please list: Please check any of the following childhood diseases you have had? Measles Chicken Pox Scarlet Fever Scarletina Diphtheria Tonsilitis Do you use any of the following products? (Please check) Cigarettes Alcohol Cigars Chewing Tobacco Pipe Snuff Marijuana Women: Please circle Are you Pregnant now? Are you taking Birth Control? Do you anticipate becoming pregnant? YES NO YES NO YES NO When was your last dental exam? Is there anything you would like to change about your smile? Are you interested in teeth whitening?
Patient Name: : Release of Information I authorize to release my protected Health Information to: Name: Relation: Phone: Name: Relation: Phone: I DO NOT authorize information to be released to anyone. I understand that I may withdraw or revoke my permission at any time. I may revoke this authorization by notifying Macri Dental in writing. Signature: : Expires one year from date signed Messages Macri Dental offers E-mail and Text Message notifications for Appointment Reminders and other patient care related information. This system will allow you to verify appointment at a time convenient to you, to request future appointments, and to keep you informed of office and patient care information. If you choose to opt-in to this system please provide us with your email, phone number on the first page. This information is only used for Macri Dental purposes and is governed by the same HIPAA protection as all other information. I authorize Macri Dental to notify me of patient care related information using these different methods. (Please circle any that apply) Text Messaging E-Mail Voicemail Signature: : Expires one year from date signed Office Financial Policies Dental insurance plans do not normally provide full coverage of your dental bill. Your dental coverage is a contract between you and your insurance company. While we will cooperate to the fullest in expediting your claim, you are ultimately responsible for your account. Your portion of the bill will be due at time of service, unless otherwise previously agreed to a written payment plan agreement. If your insurance has not paid within 60 days from the date from the date of service, we will look to you for prompt payment of the account. All costs for collection of the account, should collection procedures or small claims court become necessary, will be passed on to the patient and/or the responsible party. I understand that due to any false information, I may be subject to criminal prosecution Initial Assignment of Benefits I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to Macri Dental. Initial Insurance Regulations I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure of my protected health care information to carry out payment activities in connection with claims submitted from this office. Initial Cancelation Policy We do require a 48 hour notice for any appointment changes to avoid a $50 cancellation fee. Initial Patient Name (please print) Patient (or Responsible party) Signature
(HIPAA) I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I am authorizing you to use and disclose my protected health information to carry out: Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment) Obtaining payment from third party payers (e.g. my insurance company The day to day healthcare operations of your practice Methods of payment, including credit card information (although encrypted) will be kept safe and protected. I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected. Print Patient Name: Relationship to Patient (if signing for a minor) Signature: : Acknowledgment of Notice of Privacy Practices Notice of Privacy Practices (must be signed by ALL new patients). By signing below, I acknowledge that I have read the Notice of Privacy Practices, as mandated by the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ). Signature (If patient is a minor or disabled, the Parent, Guardian or Attorney-in-Fact must sign above and complete the Responsible Party section below) OFFICE USE Documentation of good faith To obtain patient acknowledgement that they received providers Notice of Privacy practice (For use when acknowledgment cannot be obtained from the patient.) The patient presented to the office/hospital on [insert date] 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): Signature of Employee Completing Form
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 Janet Mis (Office Manager), in person or in writing, during regular, business hours. She 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 e-mailing it to the Secretary of Health and Human Services, whose street address and e-mail address is: Office for Civil Rights - U.S. Department of Health and Human Services - 200 Independence Avenue S.W. - Room 509F, HHH Building - Washington, D.C. 20201. 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.