English – Medicaid/NCHealthChoice

Please correct the errors described below.

Health History Form

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Includes area code
Includes area code

If you are completing this form for another person, what is your relationship to that person?

Do you have any of the following diseases or problems: (Encircle DK if you Don't Know the answer to the question)

If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.

Dental Information

For the following questions, please select your responses to the following questions.

Medical Information

Please encircle your response to indicate if you have or have not had any of the following diseases or problems.

(Check DK if you Don't Know the answer to the question)

Joint Replacement

Women Only

Allergies

Are you allergic to or have you had a reaction to:
To all yes responses, specify type of reaction.

Congenital heart disease (CHD)

Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful healthhistory and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forthabove have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do nottake because of errors or omissions that I may have made in the completion of this form.

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.

FOR COMPLETION BY DENTIST

Medicaid and NC Health Choice Office Guidelines

Welcome to Oxford Dental Care! In order to provide excellent dental care, at comparable rates, this patient information serves as a communication to facilitate a mutual understanding between our practice and patients in order to achieve and maintain the highest quality of oral health care.

Please initial and sign below that you are aware and agree to the office terms, procedures, and policies.

A 72 hour notice is requested to change or reschedule an appointment reservation.
A 48 hour notice is required. Failure to give a notice or not showing up for the scheduled appointment reservation, may result in dismissal from the practice.

A copy of your insurance/dental benefit card and picture ID must be brought to every dental appointment. We are happy to file all insurance as a courtesy to our patients. Dental benefits are based on allowed procedures and plan policies provided by your insurance company and benefit provider. Any balance due to uncovered or un-allowed procedures, loss of insurance coverage, insurance participation that does not cover dental services, or any services not covered by the insurance plan, will be due to the responsible party at 100% of our current dental fee(s).

If you are 21 years of age or older, a $3.00 co-pay is due at each visit. Payment is collected at the date and time of service. We accept Cash, Money Orders, Visa MasterCard, Discover, and Care Credit. We do not offer in-house financing.

, including Initial Date any balance, whether paid by insurance or not. I authorize the use of my signature in order to submit any and all information required to process benefit claims or verification to the insurance company or companies I have provided by any form of transmission or communication.

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 Acknowledgment Of Reciept Of Notice Of Privacy Practices And Consent/ Limited Authorization & Release Form

You may use to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original.

MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE.

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.

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:
(This includes step parents, grandparents and any care takers who can have access to this patient's records):

Add new

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improve health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.

Office Use Only

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.

Your information will be encrypted.

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