PATIENT INFORMATION OFFICE PAYMENT POLICY PLEASE READ AND SIGN

Transcription

1 PATIENT INFORMATION NAME: Last First Middle Initial Preferred Name SEX: Male Female STATUS: Single Married Child Other BIRTHDATE: SOCIAL SECURITY #: ADDRESS: Street City Cnty State ZIP PHONE #: ( ) -- ( ) -- Home Work Ext. Cell YOUR EMPLOYER: Name Phone # REFERRED BY (GENERAL DENTIST ): ( ( ) ) IF YOU HAVE DENTAL INS., RELATIONSHIP TO SUBSCRIBER: Self Spouse Child NAME OF SUBSCRIBER: SOCIAL SECURITY # : FIRST NAME LAST NAME BIRTHDATE: - - SUBSCRIBER S EMPLOYER: Name Phone # HAS SOMEONE IN YOUR HOUSEHOLD BEEN SEEN HERE BEFORE? Yes No IF YES, NAME OF FAMILY MEMBER: OFFICE PAYMENT POLICY PLEASE READ AND SIGN PATIENTS WITH DENTAL INSURANCE : The fee for our doctors services is your responsibility. If you are here for a consultation, we ask that you pay the $50 exam fee today. As a convenience to you, we will help you file your insurance. If you are here for endodontic treatment, we will submit your insurance claim, but we do expect your 20% to 50% estimated co-payment today, please ask for our fees. Knowledge of your insurance coverage is your responsibility and time does not always allow us to obtain this information prior to you being seated and electing treatment. PREFERRED METHOD OF PAYMENT: CASH CHECK CREDIT / DEBIT / HSA CareCredit (Outside agency, must be approved in advance of treatment... 6 months interest free) ( ) PATIENTS WITH NO DENTAL INSURANCE : Payment in full is expected today, please ask for our fees. We offer no in-house financing; however, we utilize an outside financing agency to assist you with payment arrangements. Please see our front office staff for more information. PREFERRED METHOD OF PAYMENT: CASH CHECK CREDIT / DEBIT / HSA CareCredit (Outside agency, must be approved in advance of treatment... 6 months interest free) ALL PATIENTS: An 18% annual (1.5% monthly) finance charge is applied to balances beyond 90 days. I have read the above information and certify that I am the patient/guardian of the patient and am authorized to furnish the information requested. I understand that I, not my insurance company, am responsible for payment of the services rendered by Robert E. Jepko, DDS, PA. I further agree to be solely responsible for any collection costs associated with my account. SIGNATURE: DATE

2 MEDICAL HISTORY 1. Have you been an inpatient in the hospital or been under the care of a medical doctor during the past two years?... YES NO If yes, for what reason? 2. Are you allergic to ( i.e., itching, rash, swelling of hands, feet or eyes) or made sick by penicillin, aspirin, codeine, latex, epinephrine, or any drugs, medications or any household cleaning products? YES NO If yes, please list: 3. Have you ever been diagnosed with pseudomembranous colitis or c-diffcile colitis? Have you noticed if certain medications give you diarrhea? (name): YES NO 4. Have you ever taken or are you currently taking any biphosphonate medications, such as: Zometa, Aredia, Fosamax, Actonel, Boniva, Skelid, Bonefos/Ostac, or Didronel? (name): YES NO 5. Are you on any blood thinning medications? (name): YES NO 6. Check any of the following which you have had or have at present: HIV Positive (AIDS) Heart Failure Cancer or Tumor Hepatitis A (infectious) Heart Murmur Shortness of Breath Hepatitis B (serum) Mitral Valve Prolapse Cough, Emphysema Hepatitis C Artificial Heart Valve Tuberculosis (TB) Liver Disease Artificial Joint when? Asthma Kidney Trouble Heart Disease or Attack Hay Fever Blood Transfusion when? Angina Pectoris (chest pain ) Sinus Trouble Drug Addiction High Blood Pressure (hypertension) Allergies or Hives Hemophilia Congenital Heart Lesions Diabetes Cold Sores or Fever Blisters Heart Surgery Thyroid Disease Epilepsy or Seizures Heart Pacemaker X-Ray or Cobalt Treatment Fainting or Dizzy Spells Scarlet Fever Chemotherapy (Cancer, Leukemia) Nervousness (Excessive) Rheumatic Fever Arthritis Psychiatric Treatment Anemia Rheumatism Sickle Cell Disease Stroke Cortisone Medication Bruise Easily GERD (reflux) Glaucoma Bleeding Disorder Ulcers Pain in Jaw Joints NONE OF THE ABOVE 7. Do you have any disease, condition or problem not listed?... YES NO 8. Please list all medications you are currently taking. NONE LIST ATTACHED 9. Preferred Pharmacy Name & Location: 10. Women: Are you Pregnant? YES NO If yes, what month are you due? Are you taking birth control pills? YES NO Certain antibiotics may reduce the effectiveness of this medication. UPON COMPLETION OF ROOT CANAL TREATMENT, I UNDERSTAND THAT I AM TO RETURN TO MY REGULAR DENTIST FOR THE PERMANENT RESTORATION (FILLING AND/OR CROWN). Signature: Date: Updated: Initialed: ** CONTACT PERSON, IN CASE OF AN EMERGENCY:

3 ENDODONTIC INFORMATION AND CONSENT FORM Please be reassured that we use accepted infection control procedures and universal precautions for the protection of our patients and staff. Endodontic Root Canal Therapy, Endodontic Surgery, Anesthetics, and Medications While serious complications associated with root canal therapy are very rare, we would like our patients to be informed about the various procedures involved in endodontic therapy and have their consent before starting treatment. Endodontic (root canal) therapy is performed in order to save a tooth which otherwise might need to be removed. This is accomplished by conservative root canal therapy or, when needed, endodontic surgery. The following discusses possible risks that may occur from endodontic treatment, and other treatment choices. Risks: Included (but not limited to) are complications resulting from the use of dental instruments, drugs, sedation, medicines, analgesics (Pain Killers), anesthetics, and injections. These complications include (but not limited to) swelling; sensitivity; bleeding; pain; infection; numbness and tingling sensation in the lip, tongue, chin, gums, cheeks and teeth which is transient but, on infrequent occasions, may be permanent; reaction to injections; changes in occlusion (biting); jaw muscle cramps and spasms; temporomandibular (jaw) joint difficulty; loosening of teeth; referred pain to ear, neck, and head; nausea; vomiting; allergic reactions; delayed healing; sinus perforations; and treatment failure. Risks More Specific to Endodontic Therapy: Endodontic treatment, like treatment to any part of the body, has some risks. The risks include the possibility of instruments broken within the root canals; perforations (extra openings) of the crown or root of the tooth; damage to bridges, existing fillings, crowns, porcelain veneer or surrounding tissue; loss of tooth structure in gaining access to canals; and cracked teeth. During treatment, complications may be discovered which make treatment impossible or which may require dental surgery. These complications may include blocked canals due to fillings or prior treatment, natural calcifications, broken instruments, curved roots, periodontal disease (gum disease), and splits or fractures of the teeth. Medications: Prescribed medications and drugs may cause drowsiness and lack of awareness and coordination (which may be influenced by the use of alcohol, tranquilizers, sedative, or other drugs). It is not advisable to operate any vehicle or hazardous device until recovered from their effects. Women Taking Birth Control: Certain antibiotics may reduce the effectiveness of birth control medication. Please take necessary precautions. Other Treatment Choices: These include no treatment, waiting for more definite development of symptoms, or tooth extraction. Risks involved in these choices might include pain, infection, swelling, loss of teeth, and infection to other areas. CONSENT: I, the undersigned, being the patient (parent or guardian of minor patient), consent to the performing of procedures decided upon to be necessary or advisable in the opinion of the doctor. I also understand that, upon completion of root canal therapy in this office, I should return to my general family dentist for a permanent restoration (such as a crown, cap, jacket, onlay, or silver or white filling) of the tooth involved. I understand that with the cooperation of the patient, root canal treatment is an attempt to save a tooth which may otherwise require extraction. Endodontic treatment can be carried out successfully in most, but not all, cases. It cannot be guaranteed. Occasionally, a tooth which has had root canal therapy may require retreatment, surgery or extraction. Signature of patient, parent or guardian: Date:

4 Robert E. Jepko, D.D.S., PA 1155 Huffman Mill Road, Burlington, NC (336) FILING YOUR INSURANCE CLAIM Our office is pleased to help file your claim forms and assist you in getting your claim paid. Our office does NOT guarantee payment by your insurance company. We will make every attempt, at the beginning of your dental care, to receive verification of your policy and an estimate of what it covers. However, knowledge of your insurance coverage is your responsibility and time does not always allow us to obtain this information prior to you being seating and electing treatment. It must be fully understood that the contract is between you and your insurance company and that you are fully responsible for any amount not paid by your insurance. Our office policy regarding insurance assignment: 1. The courtesy of accepting your insurance assignment may be withdrawn if circumstances warrant. 2. If you discontinue care without the Doctor s authorization or do not return to have an emergency procedure completed, the balance of your account is due and payable in full immediately, even if your insurance has been filed. (If the insurance does pay, it will be refunded if you have a zero balance.) 3. Your insurance should pay within 30 days. If your insurance has not paid within 45 days, you must pay the balance due and be reimbursed by your insurance company when and if it pays. 4. Our office will NOT enter into a dispute with your insurance company over your claim. This is your responsibility and obligation. 5. In the event that your insurance company pays you directly, your obligation is to send us a check for your dental services immediately upon receipt of the insurance check. 6. All special arrangements regarding finances must be signed by you as the patient/guardian and our Office Manager. This office accepts cash, check (residents of Alamance County), MasterCard, Visa, and Discover as payment. An extended payment plan with 6 months free interest is available through CareCredit only. If you understand and agree with all of the above policies, please sign your name below and we will submit your insurance claim for you. Signature of Patient, Parent, or Guardian Date

5 FIRST NAME LAST NAME

6 Notice of Privacy Practices for Protected Health Information This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully! With your consent, the practice is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services. Example of uses of your health information for treatment purposes: A nurse obtains treatment information about you and records it in a health record. During the course of your treatment, the doctor determines a need to consult with another specialist in the area. The doctor will share the information with such specialist and obtain input. Example of use of your health information for payment purposes: We submit a request for payment to your health insurance company. The health insurance company requests information from us regarding medical care given. We will provide information to them about you and the care given. Example of Use of Your Information for Health Care Operations: We obtain services from our insurers or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services. Your Health Information Rights The health record we maintain and billing records are the physical property of the practice. The information in it, however, belongs to you. You have a right to: Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office. We are not required to grant the request but we will comply with any request granted; Obtain a paper copy of this Notice of Privacy Practices for Protected Health Information ( Notice ) by making a request at our office; Request that you be allowed to inspect and copy your health record and billing record you may exercise this right by delivering the request in writing to our office; Appeal a denial of access to your protected health information except in certain circumstances; Request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office; File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information; Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office. An accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing care;

7 Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office; and, Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office. If you want to exercise any of the above rights, please contact the front office staff at , in person or in writing, during normal hours. They will provide you with assistance on the steps to take to exercise your rights. You have the right to review this Notice before signing the consent authorizing use and disclosure of your protected health information for treatment, payment, and health care operations purposes. Our Responsibilities The practice is required to: Maintain the privacy of your health information as required by law; Provide you with a notice of our duties and privacy practices as to the information we collect and maintain about you; Abide by the terms of this Notice; Notify you if we cannot accommodate a requested restriction or request; and Accommodate your reasonable requests regarding methods to communicate health information with you. We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our Notice or by visiting our office and picking up a copy. To Request Information or File a Complaint If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to You may also file a complaint by mailing it or ing it to the Secretary of Health and Human Services whose street address and address is We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the practice. We cannot, and will not, retaliate against you for filing a complaint with the Secretary. Other Disclosures and Uses Notification Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.

8 Communication with Family Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person s involvement in your care or in payment for such care if you do not object or in an emergency. Food and Drug Administration (FDA) We may disclose to the FDA your protected health information relating to adverse events with respect to products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements. Workers Compensation If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation. Public Health As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability. Abuse & Neglect We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect. Correctional Institutions If you are an inmate of a correctional institution, we may disclose to the institution, or its agents, your protected health information necessary for your health and the health and safety of other individuals. Law Enforcement We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement. Health Oversight Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities. Judicial/Administrative Proceedings We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order. Other Uses Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided. Website If we maintain a website that provides information about our entity, this Notice will be on the website. Effective Date: