New Patient Information

OCCUPATION 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.

HEALTH HISTORY

Are you allergic to

For women are you

Medication- Please list name dosage, and necessity

I understand the above information is necessary to provide me with the best dental care in a safe and efficient manner. I have answered all the above questions to the best of my knowledge. Should further information be needed, you have permission to obtain this information from the respective health care provider or agency

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.

DENTAL HISTORY

Are your teeth sensitive to

Do you use

PATIENT CONSENT FORM

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPPA). I understand that by signing this consent, I authorize you to use and disclose my protected health information to carry out:

• Treatment: including direct or indirect treatment by other providers involved in my treatment
• Obtaining payment from third part payers (i.e. insurance company)
• The day-to-day healthcare operations or your practice.

I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPPA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do not agree, you are bound to comply with this restriction.

I understand that I may revoke this content in writing, at any time. However, any use or disclosure that occurred prior to the date I revoked this consent is not affected.

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 POLICY

• AS A COURTESY TO YOU, WE WILL GLADLY FILE YOUR INSURANCE CLAIMS: However, it is your responsibility to handle any problems with your insurance company. We will be happy to re-file any claims that you request after you have contacted your insurance company to verify that re-filling is necessary.
• YOU ARE RESPONSIBLE FOR ANY DEDUCTIBLE OR CO-PAYMENT AT THE TIME OF SERVICE. We will not bill you for this amount.
• OUR FEES ARE NOT DETERMINED BY INSURANCE COMPANIES. Oftentimes, our fees are lower than the allowable charge for your insurance plan; however, if our fees are greater than their allowable charge, you are responsible for the difference.
• We will try to help you understand your dental insurance and receive the maximum benefit from it; however, WE CANNOT GUARANTEE ANYTHING ABOUT YOUR INSURANCE as your contract is with the insurance company NOT with this office. All payment decisions are made by the insurance company upon their receipt of the claim; WE CAN ONLY ESTIMATE YOUR BENEFITS. It is your responsibility to know your insurance coverage.
• ANY BALANCE NOT PAID BY YOUR INSURANCE COMPANY AFTER 60 DAYS IS YOUR RESPONSIBILITY. If your balance is not paid by the due date on the invoice, a late fee of $10.00 will be added to your account.
• ANY BALANCES OVER 90 DAYS WILL BE SENT TO A COLLECTION AGENCY unless other arrangements were made ahead of time with this office. The patient understands that these services are their responsibility, regardless of insurance payment. The patient further agrees to pay nominal charges for all services and products rendered, to waive any right of notice or exemption in the state of Alabama or any other state with regard to personal property, to add one and one half (1 ½ %) per month to any balance owed, in the event of default to also pay reasonable collection charges, attorney fees, and court costs.
• REIMBURSEMENT PLANS ONLY: if your insurance coverage is through a reimbursement plan, you will be required to pay for services at the time of your visit; you will be given a receipt and an insurance claim form to be used when you file for reimbursement. No receipts will be given until charges are paid in full.
• CANCELLATION POLICY: Our office has a cancelation policy for not showing or canceling an appointment without a 24 hour notice. If appointments are cancelled without a 24 hour notice a $25.00 charge will be applied to your account balance.

I HAVE READ AND UNDERSTOOD THE ABOVE STATED POLICY IN ITS ENTIRITY AND AGREE TO ADHERE TO ITS CONDITIONS.

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.