New Patient Forms

DENTAL HISTORY

MEDICAL HISTORY

I understand that the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective healthcare provider or agency, who may release such information to you. I will notify the doctor of changes in my health or medication.

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 INFORMATION

ACCOUNT INFORMATION

PERSON FINANCIALLY RESPONSIBLE FOR ACCOUNT

CONSENT FOR TREATMENT

2. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.

3. I agree to the use of anesthetics, sedatives, and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.

4. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed-upon dates, I understand that a 1 ½ % late charge (18% APR) may be added to my account. If required, I also understand a check of my credit history may be made.

FINANCIAL POLICY

Thank you for choosing us as your dental health care provider. We are committed to excellence in providing the finest service available for all of our patients. Good communication concerning dental problems, treatment solutions, and payment arrangements is of primary importance to accomplish this goal. The following is a statement of our financial policy, which we require you to read and sign prior to any treatment.

We understand that dental insurance is an important factor for patients to consider when entering treatment. Please also understand that our treatment recommendations are based entirely upon what is best for your oral health, and not the coverage terms of any particular insurance plan. Your insurance policy is a contract between you and your insurance company, not your doctor. Most dental plans are designed to assist with limited treatment or routine maintenance, and usually carry an annual maximum. They are not designed to cover comprehensive treatment, regardless of the medical necessity.

For patients with insurance, we will be happy to provide a receipt at the end of your visit, which will enable you to file your own claim with your insurance company. You are responsible for payment in full for services rendered without regard to insurance coverage. Before beginning treatment, you are entitled to, and will be provided, a detailed treatment plan showing the number of appointments and cost of services at each. Payment for services may be made in one of the following ways:

1. Pay at each visit for services completed that day with cash, check, MasterCard, Visa, American Express, or Discover.
2. For treatment amounts over 10,000, you may receive a 5% discount when paying in full by cash or check on or before your first visit.
3. Extended financing through a third-party dental financing company. Rates and terms furnished upon request.

These policies allow us to focus all of our efforts on providing superior oral health care. We want you to be comfortable in dealing with these matters. Please ask if you have any questions regarding treatment, procedures, fees, or payment options. Thank you for your understanding.

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.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I may refuse to sign this acknowledgment.
I have been offered and/or received a copy NEW HAVEN PROSTHODONTICS Notice of Privacy Practices.

I understand that my PHI (Protected Health Information) can and will be used for purposes of treatment and for payment of both myself and/or third party. I understand that I may request a copy of the privacy policies at any time.

Expiration — 3 years from Initial Signature; Insurance Change; Patient reaches age of 18

I consent for the office of New Haven Prosthodontics to share my personal information with the following: (family, friends, etc.)

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.

NOTICE OF PRIVACY PRACTICES

This notice describes how your health information may be used and disclosed and how you can access this information. Please review it carefully.

At our office, we have always kept your health information secure and confidential. A new law requires us to continue maintaining your privacy, to give you this notice and to follow the terms of this notice. The law permits us to use or disclose your health information to those involved in your treatment. For example, a review of your file by a specialist doctor whom we may involve in your care. We may use or disclose your health information for payment of your services. For example, we may provide you with a report of your progress for your insurance company if applicable. We may use or disclose your health information for our normal healthcare operations. For example, one of our staff will enter your information into our computer.

We may share your medical information with our business associates, such as a billing service. We have a written contract with each business associate that requires them to protect your privacy.

We may use your information to contact you. For example, we may provide you with appointment reminders such as postcards and/ or a phone call. If you are not home, we may leave this information on your answering machine or with the person who answers the telephone.

In an emergency, we may disclose your health information to a family member or another person responsible for your care.

We may release some or all of your health information when required by law.

Except as described above, this practice will not use or disclose your health information without your prior written authorization.

You may request in writing that we not use or disclose your health information as described above. We will let you know if we can fulfill your request.

You have the right to know of any uses or disclosures we make with your health information beyond the above normal uses.

As we will need to contact you from time to time, we will use whatever address or telephone number you prefer. If this practice is sold, your information will become the property of the new owner.

You have the right to transfer copies of your health information to another practice. We will mail your files for you. You have the right to see and receive a copy of your health information, with a few exceptions. Give us a written request regarding the information you want to see. If you also want a copy of your records, we may charge you a reasonable fee for the copies.

You have the right to request an amendment or change to your health information. Give us your request to make changes in writing. If you wish to include a statement in your file, please give it to us in writing. We may or may not make the changes your request but will be happy to include your statement in your file. If we agree to an amendment or change, we will not remove nor alter earlier documents, but will add new information.

You have a right to receive a copy of this notice.

ACKNOWLEDGEMENT (Please note: You may refuse to sign this acknowledgement)

I have received a copy of the Notice of Privacy Practices.

Thank you, and if you have any questions about this form or the Privacy Practices, please contact our privacy officer.

ADVANCE NOTICE FOR CANCELLATION AGREEMENT

Our practice is committed to providing exceptional oral health care in a timely manner. Due to the nature
of a prosthodontic practice, a significant number of our patients present with comprehensive dental
problems, which dramatically affect their quality of life. It is our mission to improve these situations with,
proper conscientious care. Therefore, it is very important that we respect all scheduled appointments. These appointments are considered confirmed at the time they are made. We will call you one, as a courtesy, to remind you of the appointment. Because a substantial amount of time has been set aside for you, we will charge $50 per hour for appointments missed with the doctor and $25 per hour for appointments missed with the hygienist. Please contact the office two business days in advance, if you need to reschedule, to avoid this charge.

Thank you for your understanding in this matter.

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.

SIGNATURE RELEASE STATEMENT

YOUR SIGNATURE IS NECESSARY FOR US TO:

1. PROCESS ALL INSURANCE CLAIMS
2. ENSURE PAYMENT FOR SERVICES PROVIDED
3. RELEASE MEDICAL INFORMATION TO INSURANCE COMPANIES NEEDED FOR THE PROCESSING OF YOUR CLAIMS
4. RELEASE INFORMATION TO OTHER MEDICAL AND DENTAL PROVIDERS, INCLUDING LABORATORIES, WHEN NECESSARY, FOR YOUR TREATMENT.

I hereby authorize the release of all medical information necessary to process my claims and I authorize the release of this same information, when necessary, to other providers rendering medical/dental care, as well as to labs that need my information to make a diagnosis or fabricate an appliance necessary for my treatment.

I assign all medical and surgical benefits, including major medical benefits to which I am entitled, to New Haven Prosthodontics. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.

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.

PHOTOGRAPHY/IMAGING CONSENT FORM

I consent for medical imaging (photo, video, radiographic images and/or audio) to be made of myself or my child (or for person whom I am legal guardian). I understand that the information from my medical records may be used for purposes of teaching, publication, or marketing, advertising, and media (including websites, printed materials, news reporting, documentary films, commercials, television or film, social media, websites, etc.).

By consenting to this, I understand that I will not receive payment from any party. Refusal to consent to photographs, video, and/or audio recording will in no way affect the medical care I will receive. If I have any questions or wish to withdraw my consent in the future, I may contact the staff at New Haven Prosthodontics.

By signing this form below, I confirm that this consent form has been explained to me in terms which I understand that the image may be seen by members of the general public, in addition to scientists and medical researchers that regularly use these publications in their professional education. Although these photographs will be used without identifying information such as my name, I understand that it is possible that someone may recognize 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.