New Patient Adult Form

Date:

Patient Last Name:

First Name:

DOB:

Nickname:

Gender:

Male Female

Pronouns

Marital Status:

Social Security #:

Email Address:

Address: (Street)

Apartment #:

City:

State:

Zip Code:

Phone #’s:

Home:

Work:

Ext.

Cell:

Best Time To Call:

Referral Information

How did you hear about us?

Spouse or Responsible Party Information (If Different from above)

Making medical decisions?

Self Guardian Other

Name of Guardian:

If Other, Please Specify:

Making dental decisions?

Self Guardian Other

Name of Guardian:

If Other, Please Specify:

Financial Responsibility?

Self Guardian Other

Name of Guardian:

If Other, Please Specify:

Last Name:

First Name:

MI:

DOB:

Gender:

Male Female

Pronouns

Social Security #:

Email Address:

Address: (Street)

Apartment #:

City:

State:

Zip Code:

Phone #’s:

Home:

Cell:

Dental Insurance Information

Primary Last Name of Insured:

First Name:

MI:

Patient’s Relationship to Insured:

Self Spouse Child Other

Name of Employer:

Insured’s Birth Date:

ID#:

Group#:

Insurance Company

Insured Company Phone No.

Do you have secondary coverage?

Yes No

Primary Last Name of Insured:

First Name:

MI:

Patient’s Relationship to Insured:

Self Spouse Child Other

Name of Employer:

Insured’s Birth Date:

ID#:

Group#:

Insurance Company

Insured Company Phone No.

In Case of Emergency Contact

Last Name of Contact:

First Name:

MI:

Patient’s Relationship to Contact:

Spouse Child Other

If Other, please specify:

Phone #’s:

Home:

Cell:

Work:

Medical/Dental History

If Other, please specify:

Do you have any of the following?

Allergies to Anesthetics:

Yes No

If yes, please explain

General Allergies:

Yes No

If yes, please explain

Allergies to Medicine/Drugs:

Yes No

If yes, please explain

Are you allergic to latex?

Yes No

If yes, please explain

Have you ever had an adverse reaction to any dental treatment?

Yes No

If yes, please explain

Does your Physician require you to take antibiotics prior to dental treatment?

Yes No

If yes, please explain:

Please List Medications/doses you are currently taking:

Medication:

Dose:

Add medication

Are you under the care of a physician?

Yes No

Is there anything else we should know about your medical history?

Yes No

Do you grind your teeth at night or suffer from Jaw pain?

Yes No

Women:

Do you suspect that you are pregnant?

Yes No

Are you taking any Birth Control?

Yes No

Are you nursing?

Yes No

When was your last dental cleaning?

The above information is accurate and complete to the best of my knowledge and is only for use in my treatment, billing and processing of insurance for benefits for which I am entitled. I will not hold my dentist or any member of his staff responsible for any errors or omissions that I may have made in the completion of this form:

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:

Date:

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES HIPPA

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

Purpose of Consent:

By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices:

You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information, and of other important matters about you protected health information. A copy of Our Notice accompanies this consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting Jillene Dye. Telephone #: (732) 951-0099

Right to Revoke:

You will have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the contact person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

Our Policy:

Missed appointments without cancellation will result in a $35 charge. To avoid being charged please cancel your appointment 24 hours prior to your appointment.

Consent:

I give consent to the following people to have access to the information below that I have checked off. Check all that apply.

Dental Records

Health History

Referrals

Treatment Plan/Options

Insurance Information

Account Information

NAME:

RELATIONSHIP:

I, DO NOT CONSENT

have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and health care operations.

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:

Date:

Dentistry at South Brunswick and Your Insurance Plan Our Office Financial Policy

The staff at Dentistry at South Brunswick is pleased that you have insurance assistance to help with the cost of your dental care. We would like to help you obtain the maximum use of your dental plan benefits. Please read the following information on our insurance claims process so that we can work together to ensure this assistance.

Do You Accept My Insurance? How Much Will They Pay?

We currently accept all private care insurance plans (plans that do not require you to select a dentist from a pre-determined list). We estimate your portion based on the most up-to-date information on your plan, but it is ONLY AN ESTIMATE. If you would like to know your exact insurance benefit, we will be happy to file a “pre-treatment authorization” with your insurance company prior to treatment.

I Thought I Paid My Portion But I Received A Bill. Why?

We base the patient portion of your bill on our most current information on your dental plan, but there are many factors that can affect this estimate. There may be an individual or family deductible or you may have received treatment in another office which is not calculated into our database. Sometimes you may need to be referred to a specialist for care, which also is applied to your annual maximum benefits. Insurance companies do not notify us of changes to your benefits, they only notify you. If these situations apply to you, please let us know when we estimate your treatment plan so we may adjust accordingly.

Insurance Didn’t Pay, Now What?

We bill your insurance as a courtesy. If insurance does not pay within 60 days, Dentistry at South Brunswick reserves the right to request payment in full for services from you and let you collect the insurance funds that are due to you. It is important that you recognize that the insurance you have is a legal contract between YOU and your insurance company. Our office is not, and cannot be a part of that legal contract. Ultimately, you are responsible for all charges incurred in our office.

Financial Options

Dentistry at South Brunswick requests payment in full for your portion (co-pay) at the time of service. We accept cash, check, MasterCard, American Express, Discover, and Visa. If you are in need of an extended finance option, we also work with Care Credit, Chase Healthcare Advance, and Capital One. They offer plans up to 24 months with no interest, depending on your treatment plan needs. Just ask our Financial Coordinator Jill and she will give you everything you need.

We welcome you and your family and look forward to helping you get the healthy, beautiful smile you’ve always wanted. If there is anything we can do to make your visits here more pleasant, please don’t hesitate to ask.

I have read, understand, and accept the terms of the above outlined policies for insurance handling and financial commitments that I may incur as a result of treatment at Dentistry at South Brunswick.

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:

Date:

Your information will be encrypted.