Jay M. Epstein DMD PC

New Patient Medical Form

Please correct the errors described below.

Dental History

Do you have any of the following medical conditions?
Check all the apply

Patient Information

Primary Dental Insurance

Subscriber info: (if no insurance, complete for responsible party)

Secondary Dental Insurance

Subscriber info:

Medical Dental Insurance

Subscriber info:

In Case of Emergency

Referral

Authorization

I hereby authorize payment directly to Jay M. Epstein DMD PC of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment.

I also authorize Jay M. Epstein DMD PC to administer such medications and perform such diagnostic, photographic, and therapeutic and restorative procedures as may be necessary for proper dental care. Dental treatment is rendered under the general, direct, or indirect supervision of Dr. Epstein and his associates, staff members or agents as he may deem necessary. This authorization will remain in effect until canceled in writing by me.

I grant the right to the dentist to release my dental/medical histories and other information about my dental treatment to third party payors and/or other health professionals by any method, including HIPAA compliant electronic transfer. The information on this form and the dental/medical histories are correct to the best of my knowledge.

DISCLAIMER: 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.

HIPAA: Health Insurance Portability and Accountability Act of 1996

I understand that, under the Health Insurance Portability and 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 that treatment directly and indirectly.
  • Obtain payment from third party payers.
  • Conduct normal healthcare operations such as quality assessments and Physician certifications.

I have been informed by you that your Notice of Privacy Practices contains a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices.

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

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken relying on this consent.

DISCLAIMER: 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 Jay M. Epstein, DMD, PC. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.

Payment Options: Our office accepts

  • Cash or check, Visa®, MasterCard®, American Express® or Discover Card®
  • For treatment exceeding $200 we offer special financing options with convenient monthly payments available with the Care Credit healthcare credit card.

Please note:
If you choose to discontinue care before treatment is complete, your refund will be determined upon review of your case.

Payment Options:
For patients with dental insurance, we are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement for your treatment. Understand that Jay M Epstein DMD PC strives to be compliant with all matters of federal, state, and contractual guidelines. It is against federal and contractual insurance obligations for a provider to routinely write-off patient liability including copayments, coinsurance, and deductibles or offer patient discounts that may violate the federal antikickback statute or provider-collect provisions. Under such provisions, co-payments are due at the time services are rendered. Coinsurance and deductibles are due upon confirmation of the liability from the carrier.

Federal and contractual obligations also require that we not overcharge our patients more than their contractual obligations as instructed by their insurance policy. If at any time you feel, or become aware of, any fees you have paid or are asked to pay which are not reflective of your insurance explanation of benefits or Medicare Remittance Advice, please contact us

A fee may be charged for patients who miss or cancel more than 2 times in a calendar year without 48- hour notice.

Jay M. Epstein, DMD, PC charges $30 for returned checks.

If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need.

DISCLAIMER: 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.

COMMUNICATION CONSENT

Please check all that apply

I prefer confirmations, reminder and all marketing material via:

I prefer a PHONE CALL to my:

Regarding confirmations and reminders, treatment and my account.

I understand that I can withdraw my consent at my time.
DISCLAIMER: 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.

Transfer Records Form

We ask that our new patients call their previous dentist and have any/all x-rays and treatment notes sent to our office.
Remember a full set of x-rays and/or panoramic image are only allowed every 3-5 years on most insurance plans. If we do not have the current x-rays and we have to take a new set, you may be responsible for the full fee not covered by the insurance.

Please complete the following form to authorize the release of a copy of your dental records and any information related to your health history, dental health status, treatment record and radiographs from your previous office.

DISCLAIMER: 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.

Please fill and return:

All records can be e-mailed to epstein295@gmail.com

Your information will be encrypted.

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