Adult Patient Information

Date Today

Last Name

First Name

M.I.

Nickname

Address (If P.O. Box give street also)

City

State

Zip

Home Phone No.

Work Phone No.

Ext.

Cell Phone No.

Email address

Date of Birth

Social Security No.

Employer's Name

Name of Spouse

Employer's Address

Physician

IN CASE OFE AN EMERGENCY, CONTACT (Specify someone who does not live in your household.)

Name

Relationship

Home Phone No.

Work Phone No.

Who may we thank for referring you?

BILLING INFORMATION (IF DIFFERENT FROM ABOVE)

Name of Responsible Party

Address

Relationship to Patient

Home Phone No.

Work Phone No.

Ext.

Employer's Name

SSN No.

PAYMENT FOR OFFICE VISITS ARE DUE AT THE TIME OF TREATMENT. HOW DO YOU PLAN TO PAY FOR YOUR PORTION OF DENTAL TREATMENT? WE WOULD BE HAPPY TO ANSWER ANY QUESTIONS YOU HAVE. WE ACCEPT THE FOLLOWING.

Cash Check Mastercard Visa Carecredit

If yes, Name of Insurance Co.

PLEASE FURNISH INSURANCE INFORMATION

Name of Subscriber

ID No.

SS No.

Date of Birth

Employer of Insured

Group No.

PLEASE, let us know you are feeling today!

Happy Anxious Discomfort Severe Pain

What is the reason for your visit today?

MEDICAL HISTORY

Any other diseases or problems?

Pharmacy

Location

Women: Are you Pregnant?

If so, What month?

If yes, Please Explain

List any allergies

Medications taking at present

Approximately how many?

Legal Assignment of Benefits and Financial Agreement

I understand I am financially responsible for all services and fees incurred

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

I hereby authorize my insurance benefits to be paid directly and I also authorize the Doctor to release any information required to process inusrance claims

Signature

Date

Office Policies / Dental Insurance / Private Pay

We are committed to providing you with the best possible care that's why we always try to present you with the best dental solution possible to treat your personal situation. Here are some important things you should know about receiving care at our office.

Time is reserved especially for you and we strongly encourage all patients to keep their appointments. We require at least 48 hours notice to avoid a $50/hour cancellation fee (emergencies are an exception.) $100.00 fee is charged for a missed Saturday appointment.

Balances older than 60 days will be subject to a monthly $25.00 late fee until the account is brought current.

Dr. Gniadek does require payment in full, including deductible and co-payment, at the time your services are rendered unless payment arrangements have been approved in advance by our staff. We accept Cash, Check, MasterCard, Visa, Discover, American Express and Care Credit.

Once treatment has begun and then is cancelled by the patient, Dr. Gniadek reserves the right to retain a minimum of $100 of the charged fee to cover any time and materials lost.

Your dental benefits are a contract between your employer and an insurance company. If you have any questions regarding your dental befefits, please contact your employer and or insurance company directly.

We currently accept all private care insurance plans, however, we may or may not be an in-network provider for your insurance. It is YOUR responsibility to check if Dr. Gniadek is in your network upon your appointment. Although we maintain computerized histories of payment by a given company, they do change. Therefore, it is the most up to date information we have but it is ONLY AN ESTIMATE (if you would like to know your insurance benefit, we will be happy to file a "pre-treatment authorization") with your insurance company prior to treatment. Keep in mind this is not a guarantee of coverage, it does delay treatment, but will give you a better idea of out-of-pocket expenses).

We bill your insurance company as a courtesy. If insurance does not pay within 90 days, Dr. Gniadek reserves the right to request payment in full for services from you. You can collect the insurance funds that are due you. This is rare, but it is important that you recognize that the insurance you have is a legal contract between YOU and your insurance company. Our office is not and cannot be a part of that legal contract. Ultimately you are responsible for all charges incurred in our office.

In the event of a walk-in emergency during regular business hours, a $70.00 emergency fee will be charged in addition to the necessary treatment fees. Established patients will be charged a $150.00 emergency fee for after hour emergencies in addition to the necessary treatment fees.

If needed there will be a $50.00 fee for a complete copy of your dental records.

Situations of Divorce

Divorced parents bringing a child to an appointment are solely responsible for all fees incurred during each visit. Parents will not be billed separately. By initialing, you agree to pay all costs of collection (if necessary) including, but not limited to, reasonable attorney's fee.

I acknowledgement I have read and understand all the above conditions.

Signature / Name

Date

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in my treatment directly and indirectly.
Obtain payment from third-party-payers.
Conduct normal healthcare operation such as quality assessments and physician certifications.

I have received, read , and understand your Notice of Privacy Practices containing a more complete describe of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operation. I also understand you are not required to agree to my requested restriction, but if you do agree then you are bound to abide by such restrictions.

Patient Name / Signature

Relationship to patient

Date

Please list names of persons who we can release your information to:

Request for Confidential communications

Name of Patient

Date of Birth

Address

Home No.

Work No.

Cell No.

Email address

I do NOT want a reminder left at all

I do NOT want a postcard sent

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.

I understand that I will in cur a missed appointment fee should. I fail to keep my appointment (without 24hr notification).

Your information will be encrypted.