New Patient form

Please correct the errors described below.

PATIENT INFORMATION AND HISTORY

EMERGENCY CONTACT

IF PATIENT IS A CHIlD OR STUDENT FlLING PARENT'S INSURANCE:

If you (the patient) are a student, what school do you attend?

INSURANCE:

Add new row

If Yes, Please list medications (including over the counter weight reduction medications)

Add new row

Have you ever been told that you had:

I hereby confirm that the above facts are true to the best of my knowledge. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

SUMMARY Of PRIVACY PRACTICES

This summary of our privacy practices contains a condensed version of our Notice of Privacy Practices. Our full-length Notice is available at the front desk, or by contacting the office manager. This information is made available on request by a patient. THlS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUf YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THlS INFORMATION. REVIEW IT CAREFULLY We understand that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create medical records about your health, our care for you, and the services and/or items we provide to you as our patient. By law, we are required to make sure that your protected health information is kept private. How will we use or disclose your information? Here are a few examples (for more detail please refer to the Notice of Privacy Practices):

  • For medical treatment
  • To obtain payment for our services
  • In emergency situations
  • To run our Practice more efficiently and ensure all our patients receive quality care
  • For workers' compensation programs
  • To avert a serious threat to health or safety
  • For appointment and patient recall
  • In response to certain requests arising out of lawsuits or other disputes

If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the Practice, contact our office manager. All complaints must be submitted in writing. You will not be penalized for filing a complaint. You have certain rights regarding the information we maintain about you. These rights include:

  • The right to inspect and copy
  • The right to amend
  • The right to an accounting of disclosures
  • The right to request restrictions
  • The right to a paper copy of this notice
  • The right to request confidential communications

For more information about these rights please see the detailed Notice of Privacy Practices which may be obtained from the front desk, or our office manager. YOU MAY REFUSE TO SIGN THIS ACKNOWLEDGEMENT I have received a copy of Andrew R. Lullioff D.D.S.,S.C.'s Notice of Privacy Practices.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

For Office Use Only

AUTHORIZATION

Purpose: This form is used for an individual to authorize use or disclosure of the individual's protected health information for the purposes stated. SECTION A: Individual authorizing use and/or disclosure (may use patient sticker)

TO THE INDIVIDUAL: Please read the following and complete the information requested No Conditions: This authorization is voluntary. We will not condition your treatment on receiving this authorization. Effect of Granting this Authorization: The protected health information described below may be disclosed to and/or received by persons or organizations who are not subject to federal health information privacy laws. These persons or organizations may further disclose the protected health information, and it may no longer be protected by federal health information privacy laws. SECTION B: To whom the information is being authorized for release to:

SECTION C: The use and/or disclosure being authorized.

SECTION D: Expiration and revocation.

Right to Revoke: You may revoke this authorization at any time by providing verbal or written notice of revocation to Andrew R. Lulloff D.D.S., S.C. by calling (920) 593-2569 or sending it to Andrew R. Lulloff D.D.S., S.C., Attn: Privacy Official, 2981 Voyager Drive, Green Bay, WI 54311. Revocation of this authorization will not affect any action we took in reliance on this authorization before we received your verbal or written notice of revocation.

INDIVIDUAL'S SIGNATURE

If a personal representative on behalf of the individual signs this authorization, complete the following:

YOU ARE ENTITLED TO A COPY OF THIS AUTHORIZATION AFTER YOU SIGN IT. Include this authorization in the individual's records.

RESPONSIBILITY FOR PAYMENT

I agree to be and am fully responsible for total payment of services performed including any amounts not covered by any dental insurance, I may have. I understand that the parent who requests treatment and/or presents a minor child for treatment is responsible for all fees for services rendered. In case of divorce, any arrangements made through a divorce agreement are strictly between the parents and do not involve the clinic. I understand that clinic bills are due at the time of service regardless of any insurance coverage. Insurance is designed to reimburse the policyholder and is a contract between the policyholder and the insurance company. The clinic has an insurance department and will do all it can to help collect legitimate claims. In the event the insurance company is slow to pay; reduces payment because in their estimation the charges are over usual and customary; or for some reason disallows the claim, I understand payment of the account is my responsibility. (IF INSURED) I authorize the release of information including records and xrays requested by my insurance company for the purpose of determining pretreatment estimates, precertification or payment of insurance benefits. A copy of this authorization shall be as valid as the original.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

If guardian responsible for payment is other than parent:

Your information will be encrypted.