New Patient Information

INSURANCE INFORMATION

Primary Dental Insurance

Secondary Dental Insurance

ACCOUNT INFORMATION

Person ultimately responsible for account

I hereby authorize assignment of my insurance rights and benefits directly to the provider for services rendered. I fully understand I am solely responsible for any balance not paid by my insurance company (if offered at this office).

EMERGENCY CONTACT

DENTAL INFORMATION

MEDICAL HISTORY AND INFORMATION

For women:

• We invite you to discuss with us any questions regarding our services. The best Dental health services are based on a friendly, mutual understanding between provider and patient.
• Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and any other expenses incurred in collecting your account.
• I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims.
• I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.

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 Statement of Privacy Practices

I acknowledge that I have received a copy of the Statement of Privacy Practices of the offices of Gibberman Dental. The statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with the respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

Gibberman Dental reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If privacy practices changes, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed to me.

ADDITIONAL DISCLOSURE AUTHORITY

In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated 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.

Office Use Only:

Record of Acknowledgement not obtained

Dear Patients,
All of us here are committed to providing you and your family with quality dental care. We feel a clear understanding of your responsibilities is essential to the wellbeing of our relationship. If you should have any questions please feel free to ask.

Cancellation policy:
If you are unable to keep your appointment, we kindly ask that any cancellation or rescheduling of an appointment requires at least 24 hour notice by phone or email, not via text. This courtesy on your part will make it possible for us to give your scheduled appointment, including hygiene recall appointments, to another patient in need of dental treatment. Patients will be billed a minimum of $99.00 for late cancellations or no-shows without proper notice. In addition, if you are running late for an appointment, more than 15 minutes, your dental appointment may have to be rescheduled and a late / no-show fee will be assessed accordingly. We greatly appreciate your confidence in our office and look forward to serving your oral health needs.

Patients with dental insurance coverage:
Please provide us with a current insurance card, and notify us of any changes. We will contact your benefits provider to verify coverage and request a breakdown of your dental benefits.

We will do our best to explain your coverage to you. Your copay is due at the time of service. We will file claims and accept payments from your benefits provider on your behalf. Claims denied twice will become the patient's responsibility. It is the patient's responsibility to keep up with insurance benefits remaining, although we will help you with this to the best of our ability.

Return checks are subject to a $45.00 returned check fee.

Please read the following carefully and sign where indicated. If my account is turned over to an attorney for collections, I understand that I will be responsible for any additional fees added to my account, including, but not limited to broken appointment fees, billing and service charges, late fees legal fees and court costs.

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 for Testing

In order to comply with the Occupational Safety & Health Administration Bloodborne Pathogen Regulation (OSHA), we are requesting you consent to submit testing of your bloodborne pathogens (hepatitis B, hepatitis C or HIV) if an exposure occurs (needlestick injury, blood spatter) to one of the staff. Testing will be done at no cost to you. All information regarding an exposure is confidential.

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.

I hereby authorize and request you to release all of my dental records, X-rays, history and reports to

GIBBERMAN DENTAL
6303 Little River Turnpike, Suite 205
Alexandria, VA 22312

Phone: 703.823.6616

Fax: 703.823.2141

Email: contactus@gibbermandental.com

Thank you.

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.