New Patient Forms

Patient's Name

SS / HIC / Patient ID No.

Address

City

State

Zip Code

Email address

Date of Birth

Patient Employer / School

Employer

School / Address

School Phone No.

Spouse's Name

Birthdate

SS No.

Spouse's Employer

Who may we thank for referring you?

DENTAL INSURANCE

Who is responsible for this account?

Relationship to Patient

Insurance Co.

Group No.

Subscriber's Name

Birthdate

SS No.

Relationship to patient

Insurance Co.

Group No.

ASSIGNMENT AND RELEASE

I certify that I, and/or my dependent(s), have insurance coverage with

and assign directly to Dr.

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.

Signature of Patient, Parent, Guardian or Personal Representative

Relationship to Patient

Date

PHONE NUMBERS

Home Phone No.

Work Phone No.

Cell Phone No.

Spouse's Work

Best time and place to reach you

IN CASE OF EMERGENECY, CONTACT (Specify someone who does not live in your household.)

Name

Relationship to Patient

Phone No.

Alt. Phone No.

DENTAL HISTORY

Reason for today's visit

Former Dentist

City

State

Date of last dental visit

Date of last dental X-rays

How often do you floss?

How often do you brush?

DENTAL REGISTRATION AND HISTORY

Physician's Name

Date of last visit

If yes, due date

Medications

List any medications you are currently taking and the correlating diagnosis

Pharmacy Name

Phone No.

Allergies

Aspirin

Barbiturates (Sleeping pills)

Codeine

Iodine

Latex

Local Anesthetic

Penicillin

Sulfa

Other

Updates (To be filled in at future appointments)

For what conditions?

If so, what?

Patient's Signature

Date

Doctor's Signature

Date

HIPAA Privacy Rule of Patient Authorization Agreement

Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (164.508(a))

understand that as part of my health care, Ronald A. Guzman, D.D.S., originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care treatment. I understand that this information serves as:

a basis for planning my care and treatment.
a means of communication among the health professionals who may contribute to my health care
a source of incretion for applying my diagnosis and surgical information to my bill.
a means by which a third-party payer can verify that services billed were actually provided
a tool for health care operations such as assessing quality and reviewing the competence of health care professionals.

I have been provided with a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures.

I understand that as part of my care and treatment, It may be necessary to provide my Protected Health Information to another covered entity. I have the right to review Ronald A. Guzman, D.D.S. notice prior to signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me.

Privacy Rule of Patient Consent Agreement

Consent to the Use of Disclosure of Protected Health Information to Treatment, Payment, or Healthcare Operations (164.506(a))

I understand that:

I have the right to review Ronald A. Guzman, D.D.S. Notice of information practices prior to signing this consent. That Ronald A. Guzman, D.D.S., reserves the right to change the notice and practices and that prior to implementation will mail a copy of any revised notice to the address I've provided if requested.

I have the right to request restrictions as to how my protected health information may be used or disclosed to carry out treatment, payment, or healthcare operations, and that Ronald A. Guzman, D.D.S., is not required by law to agree to the restrictions requested.

I may revoke this consent in writing at any time, except to the extent that Ronald A. Guzman, D.D.S., has already taken action in reliance thereon.

Signature of Patient or Legal Representative Witness

Date

HIPAA Privacy Rule Receipt of Notice of Privacy Practices Written Acknowledgement Form

Ronald A. Guzman, D.D.S.

Acknowledgement of receipt of Information Practices Notice(164.520(a))

understand that as part of my health care Ronald A. Guzman, D.D.S. originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I acknowledge that I have been provided with and understand that Ronald A. Guzman, D.D.S. Notice of Privacy Practices provides a complete description of the uses and disclosures of my health information. I understand that:

I have the right to review Ronald A. Guzman, D.D.S. Notice of Privacy Practices prior to signing this acknowledgment.
That Ronald A. Guzman, D.D.S. reserves the right to change their Notice of Privacy Practices and prior to implementation of this will mail a copy of any revised notice to the address I've provided if requested.

Signature of Patient or Legal Representative Witness

Date

ATTENTION

EFFECTIVE DATE: AUGUST 19, 2013

THERE WILL BE A FEE OF $100.00 FOR MISSED DENTAL APPOINTMENTS AND $50 FEE FOR ANY MISSED HYGIENE APPOINTMENTS

WE REQUIRE 24 HOUR NOTICE FOR CANCELLATIONS

NO EXCEPTIONS!

Signature of Patient or Legal Guardian

Date

Your information will be encrypted.