GETTING TO KNOW YOU. 1. How important is it for you to keep your teeth healthy for a lifetime?

Similar documents
Notice of Privacy Practices

St. Michael Dental Posthumus & Biorn, Inc.

Notice Of Privacy Practices

Fairview Dental. Patient Information: Patient First Name: MI: Last: Preferred Name: Date of birth: SS#: Address: City: Zip: Home Ph: Cell: :

Home Phone Work Phone Cell Phone In the event of an emergency, who should we contact? Name Relationship Emergency Contact Phone

First&Appointment& Medical&History& Recall&Appointments& Cancelled/Failed&Appointments& Payments& Insurance&

Appointment Policy. Insurance Policy

PATIENT REGISTRATION AND MEDICAL HISTORY (PLEASE PRINT IN BLACK INK ONLY)

Regulatory Compliance

Sparta Dental Center Office Policy Statement

SMILE ANALYSIS. How s Your Smile? YES NO (Look in the mirror as you answer these questions)

NOTICE OF PRIVACY PRACTICES

Our philosophy of care governs everything we do for you. It consists of the following key elements:

FINANCIAL POLICY 1. Patients with Dental Insurance 2. Self Pay Patients 3. Billing

Notice of Privacy Practices

Patient Information. Last First MI (Preferred Name) Male Female Married Single Child. City State Zip Code Emergency Contact/Relation Phone

New Patient Information and Forms

Singh Family Dental Dr. P. Singh, PLLC

Welcome to a Brighter Morgantown!

Patient Information Patient Info. Update

Germantown Smiles,PC Germantown Road Suite 225 Germantown, Maryland

Thomas Yoon Dental Patient Information. Health Information

First Name: Middle Name: Last Name: Preferred Name: Address: City: State: Zip: Mother s First & Last Name: Mother s Home Phone: Mother s Work Phone:

HIPAA Notice of Privacy Practices

NEW PATIENT INFORMATION FORM

CHILDREN S DENTISTRY OF RANCHO CUCAMONGA Welcome to our practice!

PATIENT REGISTRATION & HEALTH HISTORY FORM

LANCE OSBORNE DENTISTRY LANCE OSBORNE, DDS SCOTT ZIMMEREBNER, DDS 245 Van Asche Loop Fayetteville, Arkansas

Patient Information: Date: Name: Married Single Minor Male Female Last First Middle Preferred. Birth date: S.S.N.# ID/DL#: Month /Day /Year

CREEKSIDE DENTAL REGISTRATION FORM. Please Print PATIENT INFORMATION. Patient s Last Name: First: Middle:

Doc Bresler s Cavity Busters - New Patient History Form

1984 Isaac Newton Sq. W. #100 Reston, VA Patient Information

Name Relationship Did you hear about us in any other way?

Child Health/Dental History Form

HAROLD GOODMAN, D.O SECOND AVENUE SUITE 405B SILVER SPRING, MD Patient Information

Patient Information. Name Soc. Sec. # Last Name First Name Middle Initial. Address. City State Zip. Home Phone Cell Phone

Spink Dentistry New Patient Questionnaire: Patient Name: Cell: General check-up Toothache Veneers. Cavity or Filling Implant Crown or Bridge

Consent for Services and Financial Policy

LITTLE ROCK FAMILY DENTAL CARE

First Name: Last Name: Initial:

York Smile Care. First: Middle: Last: Jr/Sr: Street: City: State Zip: Home Phone: Work Phone: Cell Phone: Patient's Employer:

NOTICE OF PRIVACY PRACTICES

Your Physical health is: Good Fair Poor Are you currently under the care of a physician? Yes No Please explain:

425 North Wendover Road Charlotte, NC Birthdate: Social Security #: Male Female

All Dental 76 Otis Street Westborough, MA 01581

Please be aware that this office does not do pain management and will not prescribe narcotics to new patients, nor on an ongoing basis.

Medical History. Authorization to Treat. Financial Policy. Notice of Privacy Practice

Acknowledgement of Receipt of Notice of Privacy Practices

Is this your child s first visit to the dentist? Yes No If no, date of: last exam dental x-rays fluoride treatment

OFFICE FINANCIAL POLICY

Little Peaches Pediatric Dentistry

2018 Emergency Insulin Program

Cosmetic Dental Concerns

Child s Name: Last First Middle Preferred Name. Address: Street Apt.# City State Zip. Mother Stepmother Guardian. Name: Employer: Social Security #:

Welcome To. Concord Pediatric Dentistry. First Middle Last. Street City State Zip. Dental Insurance Information

Ottesen Family Dentistry * Dr. Pamela Ottesen, DMD * *

Just for Kids Pediatric Dentistry, Ltd. Patient Information

X X Capistrano Children s Dentistry Child Patient Information

Please check if patient is a minor/child. First Name: Last Name: Middle Initial: Preferred name: Address: City: State: Zip: Home: Work: Cell:

Dental. North Naples. Laura Van Varick, D.D.S. Notice Of Privacv Practices

Trinity Family Physicians

Patient Registration

Carter Family Dentistry

Important Facts Regarding Our Practice

Picasso Aesthetic and Cosmetic Dental Spa NOTICE OF PRIVACY PRACTICES

Ottawa Children s Dentistry

Conte See Oue Exei^ing

EFFECTIVE DATE OF THIS NOTICE: 8/5/09

Regulatory Compliance

My Scottsdale Dentist. Patient Name: Date: Address: Birth Date: Gender (circle): M / F Family Status (circle):

Edward C. Smith, DMD, MPH, LLC 5650 Whitesville Road, Suite 101 Columbus, GA (706)

Patient Health History

PRIVACY NOTICE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

Sinha Clinic Foxfield Road, Suite 240, St. Charles, IL Office: (630) Fax: (630)

PATIENT INFORMATION PARENT / GUARDIAN INFORMATION

NOTICE OF PRIVACY PRACTICES

PATIENT NOTICE OF PRIVACY PRACTICES

2018 Transportation Reimbursement Program Overview

NOTICE OF PRIVACY PRACTICES ORTHOPEDIC ASSOCIATES OF LANCASTER, LTD.

Notice of Privacy Practices

Welcome. Thank you for selecting our dental health team. We look forward to working with you in maintaining your dental health.

Would you like to receive s with special offers from Carolina Vein Center? yes no

Insurance Information My Plan is a: PPO HMO POS (Point of Service) Other. Patient Name Address City State Zip

Grayson and Associates, P. C.

GENTLE DENTAL CARE OF ROCHESTER PC

SUMMARY OF NOTICE OF PRIVACY PRACTICES. Your rights related to your medical information are as follows:

City/State/Zip: Male Female Marital Status: Married Single CITY STATE ZIP. PERSON RESPONSIBLE FOR THIS ACCOUNT: Contact Phone #: ( )

TEXAS EAR, NOSE AND THROAT SPECIALISTS, L.L.P. NOTICE OF PRIVACY PRACTICES

DENTAL REGISTRATION AND HISTORY

Connecticut Asthma & Allergy Center LLC Registration Form

Secondary Insurance Co. Name & Address: Subscriber s Name: Subscriber Soc. Sec. No. Group number:

Your Child Child s Name Nickname Gender M / F Birthdate Age SSN Child s Home Address City/State Zip Phone

New Patient Registration Form. New Patient Update Date: / /

2017 Medication Assistance Program

Mother s Name: Birth date: SSN: Home Address: City State Zip Home Phone# Work # Cell # Address Employer

HEALTH HISTORY FORM. How Did You Hear About Us? Tell Us About Your Child. Person Respo sible for Account. Primary Dental Insurance

Notice of Privacy Policies

Luedtke-Storm-Mackey Chiropractic Clinic S.C. Notice of Privacy Practices. Effective September 23, 2013

Last Name: First Name: Middle Name: Suffix: SSN: DOB: Gender: Height: Weight: Last Name: First Name: Relationship to patient:

NOTICE OF PRIVACY PRACTICES

Transcription:

Robert W. Renger, D.D.S., L.L.C. 510 W. 32 nd St. Joplin, MO 64804 417-781-6700 GETTING TO KNOW YOU 1. How important is it for you to keep your teeth healthy for a lifetime? 2. If you could change one thing about your smile, what would it be? 3. What things are important to you about your dentist and/or dental practice? 4. What would you like to know about your dentist? 5. Please rate your last dental experience 1-10, 10 being the highest Please explain: 6. Do you get recurring cold sores? 7. Do you snore or have you been told you snore? 8. Do you clench or grind your teeth? 9. Do you get migraine headaches? Patient Name: Date: Personal Representative Name, if applicable: Revised 12/2012

Robert W. Renger, D.D.S., L.L.C. 510 W. 32 nd St. Joplin, MO 64804 417-781-6700 PATIENT INFORMATION SHEET Patient Name: ( ) Date: First M Initial Last Preferred Name Patient s Birth Date: Patient s Social Security #: Male Female Married Single Divorced Widowed Minor Child Patients Address: Street/PO Box City State Zip For Minors, Complete the Following: Parent or Guardians Name: First M Initial Last Landline Phone: Cell: email: IMPORTANT: PLEASE UPDATE YOUR CELL NUMBER AND EMAIL ADDRESS TO RECEIVE DENTAL CARE PROMOTIONS, SPECIALS, AND APPOINTMENT REMINDERS Drivers license #: Employer: Social Security #: Work Phone #: Employer Address: Street City State Zip Closest Relative NOT Living in Household: Name Phone Person to Call in Case of Emergency (other than spouse): Name Phone Who May We Thank For Your Referral?: Spouse Information: Name: Birth Date: Social Security #: Landline Cell Employer: Work Phone #: Employer Address: Street City State Zip Person Responsible for Account: (Relationship to Patient: ) Name: Birth Date: Driver s License #: Social Security #: Address: Phone #: Street City State Zip Employer: Work Phone #: Please continue to the back of the form.

I have dental insurance to cover my dental treatment: No Yes If you do have dental insurance, please complete the information below. Primary Dental Insurance: Name of Insurance Carrier: First M Initial Last Social Security #: Insurance ID#: Birth Date: Relationship to Patient: Name of Insurance Carrier s Employer: Dental Insurance Carrier: Group #: Insurance Address: Phone #: Secondary Dental Insurance: Name of Insurance Carrier: First M Initial Last Social Security #: Insurance ID#: Birth Date: Relationship to Patient: Name of Employer Carrying Insurance: Dental Insurance Carrier: Group #: Insurance Address: Phone #: I certify that I (the patient or parent/guardian of patient) have completed all information to the best of my knowledge. Regardless of any insurance, I am totally responsible for entire balance of the account and for all professional services performed on behalf of me or my dependent (s). Signature of Patient (or parent/guardian, if minor) Date Thank you for taking the time to complete this Patient Information Sheet! Revised 1/2013

Robert W. Renger, D.D.S., L.L.C. 510 W. 32 nd St. Joplin, MO 64804 417-781-6700 OFFICE POLICIES Payments: Payment for treatment is due in full at time of service. When scheduling treatment, half must be paid at time of scheduling appointment and the other half on day of or before services are rendered. Any special arrangements for payment must be made prior to treatment with the financial coordinator or office manager. Initial Dental Insurance: Our office files insurance claims as a courtesy to our patients. Employers offer dental benefits to help employees pay for a portion of the cost of their dental care. Dental plans are designed to share in the cost of your dental care, not to completely pay for those costs. The amount your plan pays is determined by your employer with the insurance carrier. Your dental coverage is determined not by your dental needs, but by how much your employer contributes to the plan. Our office can only estimate insurance coverage from information provided by your insurance carrier. Your insurance carrier makes the final payment determined on each claim for treatment. Any portion of co-payments and/or out of pocket expense must be paid for at the time of scheduling and time of dental services. Initial Cancelations, Reschedules and No Shows Any cancelations or rescheduling should be done as soon as the patient becomes aware of any changes. Out of courtesy to our other patients and dental team, we request two full business days minimum notice. This policy allows our office to provide timely service to all our patients that need appointments. If a patient does not call to cancel or reschedule an appointment, or does not show, it is possible that the patient may or may not be eligible to reschedule for future appointments. A $25 office fee per each missed hour will be charged. Our office is open for business Monday through Thursday 7am to 4pm. Initial I assume the responsibility of updating any changes in the Patient Information and Health History forms at future visits. I consent to the dental treatment deemed necessary by Robert W. Renger, D.D.S., L.L.C. with the understanding of a mutual agreement before treatment begins. The office of Robert W. Renger, D.D.S., L.L.C. will assist in filing dental insurance when eligible, but I understand I am responsible for all cost of any collection fees, including reasonable attorney fees. Initial I consent to the office of Robert W. Renger, D.D.S., L.L.C. taking photographs, videotape, and or digital recordings for marketing and training purposes. Initial We record all phone calls for training purposes. Signature: Date: If this is signed by a personal representative on behalf of the patient, complete the following: Personal Representative s Name: Date: Relationship to Patient: Revised 1/2013

Robert W. Renger, D.D.S., L.L.C. 510 W. 32 nd St. Joplin, MO 64804 417-781-6700 CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION Acknowledgement of Receipt of Notice of Privacy Practices SECTION A: PATIENT GIVING CONSENT Initial Patient Name: Date of Birth: SECTION B: TO THE PATIENT PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY. Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting: Contact Person: Shirley Willy, Office Manager Telephone: 417-781-6700 Fax: 417-781-6703 E-mail: SIGNATURE: shirley@drrobertrenger.com Address: 510 W. 32 nd Street Joplin, MO 64804 I,, have had full opportunity to read and consider the contents of this Consent form and the Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations. Signature: Date: If this Consent is signed by a personal representative on behalf of the patient, complete the following: Personal Representative s Name: Relationship to Patient: Date: SECTION C: RIGHT TO REVOKE: Please read carefully before signing. Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent. Signature: Date: If this Revoke of Consent is signed by a personal representative on behalf of the patient, complete the following: Personal Representative s Name: Date: Relationship to Patient: Date: YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT. Include completed Consent in the patient s chart. Revised 1/2013

ROBERT W. RENGER, D.D.S., L.L.C. 510 W. 32 nd St Joplin, MO 64804 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMTION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US. Our Legal Duty We are required by applicable federal and state law to maintain the privacy of your protected health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 01/01/2010, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and provide the new Notice at our practice location, and we will distribute it upon request. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this notice. Your Authorization In addition to our use of your health information for the following purposes, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. Uses and Disclosures of Health Information We use and disclose health information about you without authorization for the following purposes. Treatment: We may use or disclose your health information for your treatment. For example, we may disclose your health information to a physician or other healthcare provider providing treatment to you. Payment: We may use and disclose your health information to obtain payment for services we provide to you. For example, we may send claims to your dental health plan containing certain health information. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, and certification, licensing or credentialing activities. To You Or Your Personal Representative: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to your personal representative, but only if you agree that we may do so. Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your absence or incapacity or in emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information. Disaster Relief: We may use or disclose your health information to assist in disaster relief efforts. Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization. Required by Law: We may use or disclose your health information when we are required to do so by law. Public Health and Public Benefit: We may use or disclose your health information to report abuse, neglect, or domestic violence; to report disease, injury, and vital statistics; to report certain information to the Food and Drug Administration (FDA); to alert someone who may be at risk of contracting or spreading a disease; for health oversight activities; for certain judicial and administrative proceedings; for certain law enforcement purposes; to avert a serious threat to health or safety; and to comply with workers compensation or similar programs. Decedents: We may disclose health information about a decedent as authorized or required by law. National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, 2010 American Dental Association. All Rights Reserved.

and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody the protected health information of an inmate or patient under certain circumstances. Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, text messages, emails, postcards, or letters). Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice. We will charge you a reasonable cost-based fee for the cost of supplies and labor of copying. If you request copies, we will charge you $0.35 for each page, $18.00 per hour for staff time to copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure. Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations, and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. In most cases we are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in certain circumstances where disclosure is required or permitted, such as an emergency, for public health activities, or when disclosure is required by law). We must comply with a request to restrict the disclosure of protected health information to a health plan for purposes of carrying out payment or health care operations (as defined by HIPAA) if the protected health information pertains solely to a health care item or service for which we have been paid out of pocket in full. Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. Electronic Notice: You may receive a paper copy of this notice upon request, even if you have agreed to receive this notice electronically on our Web site or by electronic mail (e-mail). Questions and Complaints If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. Contact Officer: Shirley Willy or Amanda Allen Telephone: 417-781-6700 Fax: 417-781-6703 E-mail: shirley@drrobertrenger.com; amanda@drrobertrenger.com Address: 510 W. 32 nd St Joplin, MO 64804 Reproduction of this material by dentists and their staff is permitted. Any other use, duplication or distribution by any other party requires the prior written approval of the American Dental Association. This material is educational only, does not constitute legal advice, and covers only federal, not state, law. Changes in applicable laws or regulations may require revision. Dentists should contact their personal attorneys for legal advice pertaining to HIPAA compliance, the HITECH Act, and the U.S. Department of Health and Human Services rules and regulations. Revised 12/2012 2010 American Dental Association. All Rights Reserved.

2024 © financedocbox.com Privacy Policy | Terms of Service | Feedback