New Patient Form - Adult

Please correct the errors described below.

Patient Registration

Responsible Party (if someone other than the patient)

Patient Information

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Insurance Information

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Dental History

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Notice of Privacy Practices Acknowledgement

Michelle B. Deutch, D.D.S.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

*You May Refuse to Sign This Acknowledgement I have received a copy of this office’s Notice of Privacy Practices. (https://www.dentistryoverlandpark.com/docs/HIPPA1.pdf)

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Financial Policy

Thank you for choosing us as your dental health care provider. We look forward to assisting you in attaining optimum oral health. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our financial policy, which we require that you read and sign prior to any treatment. All patients must also complete our Patient Information Form as well as your insurance form, if required by your plan, before seeing the doctor. Full Payment Is Due At The Time Of Service unless other financial arrangements have been made in advance. We accept cash, check, American Express, Master Card, Visa, and Discover cards. Other financial services are available through Care Credit. A monthly billing fee of 1.5% or $5.00, whichever is greater, will be added to all accounts that remain unpaid after 60 days. If it becomes necessary to use other means for collecting payment, the patient is responsible for any and all costs, fees, and attorney fees incurred. Regarding Insurance Our office requires that you pay your deductible and co-payment, if applicable, at the time of service. While every effort will be made to maximize your insurance benefits, the balance is your responsibility, whether your insurance company pays or not. If your insurance company has not paid your claim within 60 days, the balance will be automatically billed to you. Please be aware that some and perhaps all of the services provided may be non-covered services and not considered reasonable and necessary under your policy. We will file insurance claims for you if you bring all insurance information and a completed insurance claim form, if required by your plan. Information regarding insurance benefits is the responsibility of the patient. Estimates given by our office are not a guarantee of benefits. We cannot be held responsible for the benefits paid, or not paid, by your insurance company. Emergency Care All emergency care patients are expected to remit payment at the end of the appointment. Missed Appointments Unless canceled at least 24 hours in advance, our policy is to charge for missed appointments at the rate of a normal office visit. Please have the courtesy to give us at least 48 hours notice so that we may help serve other patients wanting treatment. Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns.

I have read this Financial Policy, and understand and agree to this Financial Policy. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize Dr. Michelle Deutch to use or disclose my Personal Health Information (PHI) as described below. I understand that, if the organization authorized to receive my PHI is not a health plan or health care provider, the released PHI may no longer be protected by federal privacy regulation. Our Notice of Privacy Practices provides detailed information about how we may use and disclose this protected health information. You have a legal right to review our Notice of Privacy Practice. It is available upon request.

Patient authorizes communication with family/friends regarding your care and test results.

Additional authorized party

Patient authorizes communication with family/friends regarding your account and billing.

Additional authorized party

Patient authorizes communication with a primary care physician or other physicians (first and last name):

Additional Physician

You have the right to revoke this consent in writing, except to the extent we already have used or disclosed your PHI in reliance on your consent.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Credit/Debit Policy

I understand it is the policy of Michelle Deutch, D.D.S. to secure my credit or debit card information at the time of my visit. The office acknowledges that we must comply with the provisions of the U.S. law. If, after a claim has been submitted to my insurance carrier: 1) the claim is denied for any reason: OR 2) there is a patient liability (I.E. Deductible, Co-insurance, etc.) the office will send a statement notifying me of the balance. If this amount is not paid within 60 days, then my credit or debit card will be charged for the entire balance owed for treatment of services to me. I understand my insurance company will also provide notification of these charges with an explanation of benefits. In the event this amount exceeds $250.00, the office will provide a courtesy call to my phone number. I understand that in the event my credit or debit card has been charged for treatment or services, and then my insurance carrier subsequently makes a payment to the office for those charges, the office will issue a credit to my credit or debit card.

I hearby authorize Michelle B Deutch, D.D.S. and its designated employees to charge my credit/debit card as designated above. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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