New Patient Information [English]

Patient Information

Name

Today's Date

Address

City

State

Zip Code

Nickname

Home Phone

Work Phone

Cell Phone

Email address

SS#

Birthdate

I was referred to Z dentistry by

Friend

Yelp

Google

Insurance Co.

Z dentistry Website

Driving By

CareCredit

Other

If a friend, please indicate name

If other, please specify

Insurance Information

Insured Person’s Name (if not you)

Insured Person's Birthdate (if not you)

Name of Insured Person's Employer

Dental Insurance Company

Your Insurance ID #

Your SS#

Insured Person's Address (if not you)

City

State

Zip Code

Dental History

Former Dentist

Date of last dental X-rays

Date of last dental care

I have sores/growths in my mouth

How often do you brush?

How often do you floss?

Medical History

Physician

Physician’s Phone Number

Please list your medications and dosages

Add Medications

Do you need to Pre-Medicate with Antibiotics before dental procedures?

Yes No

Have you had a surgery OR been hospitalized in the last 12 months?

Yes No

Type of Surgery

Date

If other allergies, please list

I Smoke or Use Tobacco Products

Yes No

For Women Patients

Are you pregnant?

Yes No

Are you nursing

Yes No

Do you take birth control pills?

Yes No

How many weeks pregnant are you?

I understand that I am responsible for all charges whether or not I have insurance. The information I have given above is accurate to the best of my knowledge

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

Signature

Date

Authorization to Bill Insurance

I certify that I, and/or my dependent(s) have insurance coverage and that I assign all insurance benefits directly to Dr. Aaron Sanders. I authorize Z dentistry to release any information to my insurance company(ies) and their agents necessary to secure the payment of benefits.

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

Signature

Date

OFFICE AND FINANCIAL ARRANGEMENTS

We are delighted that you have chosen us to be your dental health provider. We are committed to providing you with exceptional dental care. We will always present you with appropriate and complete treatment options regardless of cost or insurance considerations. We respect your right to choose the care that fits your needs and desires.

APPOINTMENTS

Your appointments are scheduled on your request and at your convenience. You will receive appointment reminders by text, email and/or phone calls. Please stay in touch

Your appointments must be confirmed. This is very important to us. You can Confirm Appointments via text, email or phone call.
Rescheduling Fee of $50 will be charged If you cancel an appointment with less than 2 business days’ notice or are more than 10 minutes for your scheduled appointment.
Or if you fail to show for 2 appointments you will be dismissed as a patient of Z dentistry.

PAYMENT OPTIONS

Z dentistry offers membership plans which cover routine and preventative dental care including a 20% discount for treatment services.
Your payment is required at the time of treatment.
Cash, personal checks, Mastercard and Visa cards are accepted as payment.
CareCredit financing is available for those who desire a payment plan.
If you have insurance, we will reduce your payment by the amount of your insurance company’s estimated payment.

INSURANCE BILLING

All services are provided directly to you and are your financial responsibility. We can estimate what your insurance company will pay, but insurance companies give estimates only.

Dental insurance plans are designed by your employer to share in your dental costs. Most plans cover between 50% and 80% of the cost of dental treatment. Z dentistry cannot guarantee the amount of your coverage or the details of your dental plan

As a courtesy to you, Z dentistry will process your insurance claim and accept payment from your insurance company.

If your insurance does not pay within 45 days you are responsible for immediate payment of your bill.

(YOUR INITIALS HERE) I understand that I am responsible for my dental bill.

DELINQUENT ACCOUNTS

Should your account become delinquent (60 days or older), interest charges will accrue at the rate of 18% APR. If your account is turned over to a collection agency, collection costs (40%) and attorney fees will be added to your balance

Returned checks will be assessed a $35 charge

Thank you for reading and understanding our office guidelines. We welcome your questions

i have read all information stated above

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

Print Name / SIgnature

Date

HIPAA RELEASE

United States privacy laws (HIPAA) say that we (Z dentistry) cannot discuss any part of your care or bills with anyone unless we have your written permission. This information includes:

Appointment times and reasons for the appointment
Tests and test results
Billing and
If you are a patient at Z dentistry

Please list the people with whom you allow Z dentistry to share your information.

authorize the Doctor and Staff of Z dentistry to release my protected health information to the following:

Add Names

I do not allow anyone to receive my protected health information.

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

Patient or Legal Guardian Signature

Date

HIPAA NOTICE OF PRIVACY PRACTICES

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

It describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations and for other purposes required or permitted by law. It also describes your rights to access and control your protected health information (PHI). Protected health information is information about you that may identify you and that relates to your past, present and future physical, dental or mental health or condition and related dental or health care services.

Treatment

We may use or disclose your PHI to a physician or other healthcare provider providing treatment to you. For example, your PHI may be provided to a dentist to whom you have been referred to ensure that the dentist has the necessary information to diagnose or treat you

Payment

We may use and disclose your PHI to obtain payment for services we provide to you

Healthcare Operations

We may use and disclose your PHI in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of a healthcare professional, evaluating practitioner and provider performance, conducting training programs, and accreditation, certification, licensing or credentialing activities.

Appointment Reminders

We may use or disclose your PHI to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

Your Authorization

In addition to our use of your PHI for treatment, payment or healthcare operations, 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.

Required by Law

We will use or disclose your PHI when we are required to do so by law. These situations include public health issues, communicable diseases, health oversight, abuse, neglect, Food and Drug Administration requirements, legal proceedings, law enforcement, coroners, funeral directors, and required uses such as disclosures relating to organ donation, research, criminal activity, military activity, national security, and workers’ compensation.

Patient Rights

Access: You have the right to look at or get copies of your PHI. Your request must be in writing. We can charge you a reasonable cost-based fee for expenses such as copies and staff time.

Disclosure Accounting

You have the right to receive a list of instances in which we or our business associates disclosed your PHI for purposes, other than treatment, payment, healthcare operations and certain other activities.

Restriction

You have the right to request that we place additional restrictions on our use or disclosure of your PHI. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication

You have the right to request in writing that we communicate with you about your PHI by alternative means or to alternative locations.

Amendments

You have the right to request in writing that we amend your PHI. We may deny your request under certain circumstances.

Electronic Notice

You have the right to receive a paper copy of this notice even if you agreed to accept it electronically

QUESTIONS AND COMPLAINTS

Please contact us for more information about our privacy practices or if you have questions or concerns

If you feel that we have violated your privacy rights please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number. You may also complain to the U. S. Department of Health and Human Services.

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.

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

Signature

Date

Number

Your information will be encrypted.