Jay M. Epstein DMD PC

New Patient Medical Form

Please correct the errors described below.

PLEASE NOTE: ALL appointments MUST be confirmed in order to avoid cancellation.

ADDRESS

INSURANCE POLICY 1

INSURANCE POLICY 2

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.

Medical History Information

List all medications that you are now taking:

Add Medication

Preferred Pharmacy

PLEASE SELECT ALL THAT APPLY TO YOU. INITIAL WHEN COMPLETED

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.

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 that your electronic signature is the legal equivalent of your manual signature on this application.

Financial Agreement

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.

Transfer Records Form

PERSONAL

ADDRESS AND HOME PHONE

Dependent(s):

Add Dependent

Previous Office 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.

Release of information pertaining to the above listed patient(s)

Please email recent x-rays and records to epstein295@gmail.com

Thank You

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