New Patient Paperwork

Please correct the errors described below.

Dental Insurance Information

Add Secondary Insurance

Dental History

Please answer yes or no to the following..

Personal History

Gum & Bone

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

Please answer yes or no to following..

DO YOU HAVE OR HAVE YOU EVER HAD

Please list your CURRENT medications

Add Medications

Please advise us in the future of any change in your medical history or any medications you may be taking.

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.

HIPPA Patient Consent

I understand that the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information (PHI). 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 a third-party payer
  • Conduct normal health care operations, such as quality assessments and physician certifications

You have informed me of your Notice of Privacy Practices, which 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 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 used or disclosed to carry out treatment, payment, or health care operations. I also understand 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 action 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.

Authorization Responsibility Agreement

We welcome you to our office and look forward to working together with you to restore your oral health. Periodontitis is a chronic disease of the supporting structures of the teeth. It is generally not painful, and as such, many people are not aware of its silent progression. However, with proper therapy, and your commitment, we can do much to halt the disease process and restore your dentition to a state of health.

It is our desire to do everything necessary to attain a successful result. Treatment success also depends on your complete understanding of all that will be discussed at your consultation. The treatment plan represents anticipated therapy based upon your most recent examination and current radiographs. Since further damage can occur with delay, this plan can only remain valid if treatment is initiated promptly. Extended delays can alter the proposed therapy. Please do not hesitate to contact us if you have any questions.

Financial Arrangements

We are aware that comprehensive periodontal care may involve a large investment of both time and money. Our office is willing to work with you to help meet this financial obligation. It is our policy to make financial arrangements at the initial consultation appointment for further appointments. Payment is expected and will be collected at the time treatment is rendered. If necessary, a payment plan can be arranged, but this must be discussed prior to your surgical appointment

Dental Insurance

Our office staff will process your claim with your insurance company for you. Please be aware of your insurance requirements, benefit maximums, and limits for procedures done in our office. YOU are responsible for full payment of your account. Portions of your bill may not be paid by your insurance company. Insurance co-payments (your portion) are due at the time of therapy unless prior arrangements have been made. you must remember that your dental insurance carrier is a "for profit" entity that may not necessarily have your best dental care in mind. We will give you a "good faith" estimate based upon your real-time dental insurance information. This may not represent your exact fee. Your insurance may deny or compensate more or less than expected by our office.

Authorization Responsibility Agreement

I hereby authorize my insurance company to pay the proceeds of any benefits due to me, directly to Jeffrey E. Felzer. DMD PC (A copy of this form can be considered as an ORIGINAL for insurance purposes.)

I acknowledge and understand that I am responsible for all charges for any services rendered to me or any member of my family. Although I have requested the doctor to bill my insurance company on my behalf, I clearly understand that it is still my responsibility to make sure that the bill is paid within 60 days. If for any reason the insurance company does not pay any portion of my bill, I further agree to make arrangements for prompt payment of the bill.

Delinquent accounts will be assessed a service fee and be subject to a finance charge of 1.5% (18% per annum) on the unpaid balance until the account is paid in full. All costs associated with collection of delinquent accounts will be the responsibility of the patient or that person responsible for the account.

PLEASE BE AWARE THAT A CHARGE WILL BE MADE FOR BROKEN APPOINTMENTS

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.

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