New Patient Forms

Please correct the errors described below.

Dear New Patient,

Welcome to our practice! We appreciate the trust you have shown in us by selecting our office to provide your dental care.

Because your dental concerns are our priority, we strive to provide you with the highest quality dental care. That is why we keep abreast of new dental techniques and continually improve our professional skills and judgment. Most importantly, we are sensitive to our patient's feelings and encourage open communication about your dental care.

On your first visit with us, we will carefully listen to your dental concerns and attempt to answer all of your questions thoroughly. You can expect a thorough oral examination including a Full Mouth Series of X-Rays, a preventative teeth cleaning, professional fluoride treatment and a discussion of the most appropriate treatment and a discussion of the most appropriate treatment to meet your oral health goals. If you had a Full Mouth Series of X-Rays taken at another dental office within the past three years, it is your responsibility to acquire a copy of them and bring them with you to your first appointment. If you have not had a Full Mouth Series or a Panoramic X-Ray in the past three years or do not obtain a copy of them, we will take them for you at your first appointment.

Unless an emergency occurs, you can expect us to be on time. We appreciate you being prompt also. If you need to reschedule an appointment, Please give us at least 48 hours notice.

Enclosed you will find our Registration form, Health questionnaire, HIPPA Consent form, Cancellation Policy, Consent to Talk form, as well as our Financial & Insurance Policy form. Please complete it at your convenience and bring it with you to your first visit.

We look forward to meeting you at your scheduled appointment. If you have any questions, Please feel free to call us at (732) 974-9494.

Cordially,

W. Scott Steiner, D.M.D.

REGISTRATION AND TREATMENT

PATIENT INFORMATION

PRIMARY INSURANCE

Person Responsible for Account

ADDITIONAL INSURANCE

DENTAL HISTORY

MEDICAL HISTORY

Women


MEDICATIONS

List medications you are currently taking:

Add medication

NEVER DISCONTINUE OR MODIFY ANY MEDICATION YOUR PHYSICIAN HAS PRESCRIBED FOR YOU UNLESS INSTRUCTED BY YOUR PHYSICIAN


ALLERGIES

Add new row

AUTHORIZATION

Name of Insurance Company(ies)

and assign directly to Dr. Steiner of Elegant Smiles of Sea Girt, LLC

all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.


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.

Payment is due in full at time of treatment unless prior arrangements have been approved.

Receipt of Notice of Privacy Practices - Written Acknowledgement Form

I, have received a copy of Elegant Smiles of Sea Girt, LLC's Notice of Privacy Practices.


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.

PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

I hereby give my consent for Elegant Smiles of Sea Girt, LLC to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). (Elegant Smiles of Sea Girt, LLC Notice of Privacy Practices provide a more complete description of such uses and disclosures.)

I have the right to review the Notice of Privacy Practices prior to signing this consent, Elegant Smiles of Sea Girt, LLC, reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to:

Dr. William Steiner

Privacy Officer

Elegant Smiles of Sea Girt, LLC

2130 Highway 35, Suite 211

Sea Girt, N.J. 08750

With this consent, Elegant Smiles of Sea Girt, LLC may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, payment of fees, and any calls pertaining to my clinical care, including laboratory results among others.

With this consent, Elegant Smiles of Sea Girt, LLC may mail to my home or other alternative location any items that assist the practice in carrying out the TPO, such as appointment reminder postcards, and patient statements as long as they are marked Personal and Confidential.

With this consent, Elegant Smiles of Sea Girt, LLC may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder postcards and patient statements. I have the right to request that, Elegant Smiles of Sea Girt, LLC restrict how it uses or discloses my PHI to carry out TPO. However, the practice in not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting Elegant Smiles of Sea Girt, LLC use and disclosure of my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Elegant Smiles of Sea Girt, LLC may decline to provide treatment to me.


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.

Cancellation / Missed Appointment Policy

Our Practice is dedicated to quality care and exceptional service. We respect the importance of your time and work very hard to schedule appointments that accommodate the very busy scheduling need of all our patients. In return, we ask that patients make every effort not to change reserved dental appointments. When appointments are missed or little notice is given, other patients who need appointments have to wait. Also, missed or broken appointments interfere with your dental treatment. If an appointment needs to be changed, we require a 24- Hour notice so that we may accommodate other patients. A charge will be applied to broken or missed appointments without 24-hour notification. We appreciate, and thank you for your cooperation.


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.

Consent/Permission to Talk

To: Elegant Smiles of Seagirt, LLC

2130 Highway 35 Suite 211

Sea Girt, New Jersey 08750

To exchange information with:

Regarding my treatment plan, services rendered, dental insurance and finances.

I understand that my records are treated with the strictest confidentiality, and will not be disclosed without my permission, except when, in the judgment of the practice/clinician, such disclosure is necessary to protect me or someone else from imminent physical or psychological danger.

I also understand that I can revoke this consent at any time in writing, except to the extent that the person who is to make the disclosure or the person receiving the information has already acted upon it. I understand that this consent expires automatically as described below. I understand that I may request further explanation of this form at any time. I understand that I can receive a copy of this form upon my request.

I understand the content of this form as it has been explained to me.

The authorization of this form is valid until I am no longer a patient at Elegant Smiles of Sea Girt.


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.

Revocation of Consent/Permission to Talk


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

Thank you for selecting us as your dental health provider! The following information describes our updated office Financial Policy. Our primary goal is that you receive the optimal treatment needed to restore and maintain your dental health. Therefore, if you have any questions or concerns about our financial policies, please do not hesitate to ask us.

Payment for treatment is due at the time services are rendered. We accept cash, personal checks (with a driver's license), and for your convenience MasterCard, Visa, Discover and American Express. Our office also offers interest free options for extensive treatment plans. Our office will file your insurance claims for you as a courtesy.

1) Your insurance policy is a contract between you, your employer, and your insurance company. Our financial relationship is with you, not your insurance company.

2) All charges are your responsibility. Not all services are covered benefits. Some insurance policies may downgrade certain services they will not cover. Estimated co-payments are calculated based upon coverage information provided to us by your insurance company.

3) Fees for these services, along with unpaid deductibles and co-payments are due at the time of treatment.

4) Any outstanding claims 60 days and over will be patient's responsibility to pay until the claim is resolved.

5) Balances 90 days and older including missed appointment fees may be subject to additional collection fees and finance charges of 25% of the total unpaid balance. A $30 finance charge will be applied for returned checks.

6) It is the sole responsibility of the patient to maintain student status with their insurance company. If a claim is denied because of student status not being verified, our financial policy stated above will take effect.

We understand that temporary financial problems may affect timely payments of your balance. We encourage you to communicate any such issues so that we may assist you in the management of your account.

Again, thank you for choosing Elegant Smiles of Sea Girt, LLC as your dental provider. We appreciate your confidence in us and the opportunity to serve you.

I have read the above stated office and Financial Policies and I understand that I am responsible for payment of all dental services.


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.

(Parent or Guardian)

NOTICE FOR ALL PATIENTS WITH INSURANCE

We strongly urge you to familiarize yourself with the benefits and exclusions in your insurance contract. This information can be found in your insurance booklet, or by calling the phone number on your insurance card. As we deal with virtually hundreds of different insurance carriers and each has its own individual clauses, our practice cannot guarantee all services provided will be covered. Payment for those services rejected or not covered are the responsibility of the patient or guarantor.

PLEASE KNOW YOUR OWN INSURANCE


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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