NEW PATIENT INFORMATION

Transcription

1 NEW PATIENT INFORMATION Today s Date: / / Patient Name: Birth Date: / / Patient lives with: Both parents Mother Father Other: Father s Name: Mother s Name: FIRST MIDDLE LAST FIRST MIDDLE LAST Street Address: Street Address: Town: Zip: Social Security #: D.O.B.: Home Phone: Work Phone: Cell Phone: Employer: Employer Address: Town: Zip: Social Security #: D.O.B.: Home Phone: Work Phone: Cell Phone: Employer: Employer Address: DENTAL INSURANCE INFORMATION PRIMARY DENTAL INSURANCE SECONDARY DENTAL INSURANCE Subscriber Name: Subscriber Name: Insurance Co. Name: Insurance Co. Name: Group Plan/Employer s Name: Group Plan/Employer s Name: Group #: Group #: Insured ID #: Insured ID #: Ins. Co. Address: Ins. Co. Address: Ins. Co. Phone #: Ins. Co. Phone #:

2 As a courtesy, we accept assignment of benefits from your insurance carrier. As we deal with insurance on your behalf, carriers require that we keep your signature on file. Please sign the statements below such that we may offer this service. I have reviewed the treatment plan(s) and I authorize the release of any information relating to the claim(s). I hereby authorize direct payment to the above named dentists of the group insurance benefits otherwise payable to me. Signature of insured parent / guardian LEGAL ASSIGNMENT OF BENEFITS AND RELEASE OF HEALTH PLAN DOCUMENTS In considering the amount of healthcare expenses to be incurred, I, the undersigned, have insurance and / or employee dental care benefits coverage with the above captioned, and hereby assign and convey directly to Coastal Pediatric Dental & Anesthesia all dental care benefits and/or insurance reimbursement, if any, otherwise payable to me for services rendered from such doctors and practice. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the doctors to release all information necessary to process this claim. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to such doctor and clinic any and all plan documents, insurance policy and/or settlement information upon written request from such doctor and clinic in order to claim such benefits, reimbursement or any applicable remedies. I authorize the use of this signature on all my insurance and/or employee health and dental benefits claim submissions. I hereby convey to the above named doctors and clinic to the full extent permissible under the law and under any applicable insurance policies and/or employee health care plan any claim, chose in action, or other right I may have to such insurance and/or employee health care benefits coverage under any applicable insurance policies and/or employee health and dental care plan with respect to medical expenses incurred as a result of the services I received from the above named doctors and practice and to the extent permissible under the law to claim such medical benefits, insurance reimbursement and any applicable remedies. Further, in response to any reasonable request for cooperation, I agree to cooperate with such doctors and practice in any attempts by such doctors and practice to pursue such claim, chose in action or right against my insurers and/or employee health and dental care plan, including, if necessary, bring suit with such doctors and practice against such insurers and/or employee health and dental care plan in my name but at such doctors and practice s expenses. This assignment will remain in effect for seven years or until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement. I have read your authorization and legal assignment of benefits and agree to its terms. My signature authorizes you to disclose my PHI in the manner described above and acknowledges that I will receive a copy of this completed form for my own records. By signing below you acknowledge and accept legal assignment of benefits. Signature of insured parent / guardian Relationship to patient Date For those patients without insurance coverage, payment in full is required at the time of the treatment. For patients with insurance, the copay and/or deductible is due at the time of treatment. The parent who accompanies the child to our office is responsible for payment at the time of service unless arrangements have been made prior to the visit. All office correspondence will be addressed to the child s place of residence. It is important that you keep our office aware of changes in your address, phone numbers, and insurance status. By signing below you acknowledge that you understand our office policies. Signature of parent / guardian Relationship to patient Date

3 Pediatric Health History Patient Name: Preferred Name: Birth Date: Gender: Patient Address: Parent/Guardian Name: Pediatrician s Name: I. Please Mark Appropriate Answer: (leave blank if you do not understand the question) 1. YES NO Is your child s general health good? 2. YES NO 3. YES NO 4. YES NO 5. YES NO 6. YES NO 7. YES NO 8. YES NO II. Does Your Child Have or Has Your Child Had: 9. YES NO Asthma or trouble breathing? 10. YES NO Earaches or ear problems? 11. YES NO Hearing problems? 12. YES NO Eye problems? 13. YES NO Speech problems? 14. YES NO Sinus problems? 15. YES NO Cleft lip / cleft palate? 16. YES NO Apnea / snoring? 17. YES NO Heart murmur or other heart problems? 18. YES NO Rheumatic fever or rheumatic heart disease? 19. YES NO Skin problems? (e.g. eczema, hives, impetigo) III. Does Your Child Have or Has Your Child Had: 31. YES NO 32. YES NO 33. YES NO 34. YES NO 35. YES NO 36. YES NO Fainting or dizziness? Autism? Developmental delays or growth delays? Learning Disorders? Attention deficit / hyperactivity disorder (ADHD) Mental problems or behavior disorders? 37. YES NO Brain or head injury? IV. Does Your Child Have or Has Your Child Had: 45. YES NO 46. YES NO 47. YES NO 48. YES NO 49. YES NO Was your child born prematurely? Cerebral Palsy? Epilepsy, convulsions or seizures? Headaches or migraines? Hydrocephaly or shunts? Today s Date: Phone: Pediatrician s Phone: If YES, how many weeks? Has your child been hospitalized or had surgery? If YES, explain: Is your child being treated by a physician now? Date of last medical exam: If YES, for what? Does your child take any medicine / medications? (e.g. presciption/over the counter/herbal) If YES, what? Does your child have any allergies to drugs, food, other (e.g. latex)? If YES, what and explain type/severity of reaction? Has your child had problems with prior dental treatment? Date of last dental exam: If YES, please explain: Is your child in pain now or having a problem with their teeth? If YES, please explain: 20. YES NO 21. YES NO 22. YES NO 23. YES NO 24. YES NO 25. YES NO 26. YES NO 27. YES NO 28. YES NO 29. YES NO 30. YES NO 38. YES NO 39. YES NO 40. YES NO 41. YES NO 42. YES NO 43. YES NO 44. YES NO 50. YES NO 51. YES NO 52. YES NO Radiation Treatment? Please list to what parts of the body and when: High Blood Pressure? Cystic Fibrosis? Ulcers or stomach problems? Eating disorder / unusual diet? Hepatitis, jaundice, liver disease? Weight loss? Prolonged diarrhea? Bladder or kidney problems? Arthritis or joint problems? TMJ or jaw joint problems? Scoliosis or spine problems? Psychiatric treatment? Diabetes / high blood sugar? Thyroid problems? Anemia? Blood disorder or transfusion? Excessive bleeding / hemophilia? Sickle cell disease /trait? Cancer or tumor? Immune disorder? Chemotherapy?

4 Pediatric Health History V. Does Your Child Have or Has Your Child Had: 53. YES NO Measles / Rubella? 59. YES NO Tuberculosis (TB)? 54. YES NO Mumps? 60. YES NO Whooping Cough / Pertussis? 55. YES NO Chicken Pox / Varicella? 61. YES NO Cytomegalovirus (CMV)? 56. YES NO Scarlet Fever? 62. YES NO HIV / AIDS? 57. YES NO Mononucleosis? 63. YES NO Problem with general anesthesia? 58. YES NO Strep Throat? VI. Does Your Child Have or Has Your Child: 64. YES NO Smoke tobacco? 66. YES NO Use recreational drugs? 65. YES NO Chew tobacco or snuff? 67. YES NO Use alcohol? VII. Females (Teens) Only: 68. YES NO Is your child taking birth control pills? 69. YES NO Could your child be pregnant? VIII. All Patients: 70. YES NO Does your child have / had any other diseases, medical problems or syndromes not listed here? If YES, please explain: 71. YES NO Does your child play organized sports? If YES, please explain: 72. YES NO Does your child wear a helmet or mouthguard when playing recreational or organized sports? If YES, please explain: 73. YES NO Is your child up to date on all their vaccinations? IX: Emergency Contact Name: Relationship to the patient: Phone: To the best of my knowledge, I have answered every question completely and accurately. I will inform Coastal Pediatric Dental & Anesthesia of any change in my child s health and / or medications. Parent or Guardian s signature: Date: Relationship to the patient: Patient s name: Recall Review: VA Law requires an updated medical history with every sedation or anesthesia appointment and at least annually. A new form must be completed with any changes in health or medications. Parent or Guardian s signature: Parent or Guardian s signature: Date: Date: Practitioner s signature: Date:

5 Appointment Policy COASTAL PEDIATRIC DENTAL & ANESTHESIA OFFICE POLICIES When you schedule an appointment for your child at Coastal Pediatric Dental & Anesthesia, that time period is reserved specifically for them. Changes to the appointment affect our dentists, team, and other patients, so we ask that you call at least 48 hours in advance if you need to cancel an appointment. Here are some other points about dental appointments that we ask you to remember: Please arrive minutes in advance so your child can receive dental care on time and you can complete any additional paperwork. Please accept our apology in advance if your appointment is delayed when we accommodate an injured child for dental emergency care. We would do the same if your child were in need of emergency treatment. o Please note that surgical and anesthesia appointments require our doctors individual attention until all necessary care is provided. We will devote the same undivided attention to your child. If you arrive 15 minutes late for an appointment, you will be asked to reschedule at the next available time. If two missed or broken appointments occur consecutively without notice of cancellation, then our office reserves the right to not reschedule the appointment. We also reserve the right to not reschedule general anesthesia appointments for repeat noncompliance or cancelling without notice. Broken appointments are subject to a $50.00 fee. Coastal understands the value of school and education. Unfortunately, it is not possible for Coastal to treat all children at hours that do not interfere with school or work. However, we are happy to provide a work or school excuse with a doctor s signature so that the absence will be excused. Financial Policy Coastal Pediatric Dental & Anesthesia thanks you for choosing our office for your child s dental care. We are committed to their oral health and wellness. We ask that you understand that the payment of dental fees is considered part of your child s care. The adult who brings a child to Coastal is responsible for the payment of their dental care. We cannot send statements to other persons. Payment is expected at the time of service. We will put aside the part of the balance your insurance provider covers for 60 days. If insurance does not pay the balance within this time period, then you are responsible for any remaining balance or unpaid bills. Understand that most insurance companies only pay a portion of dental fees and we are legally required to have you pay your part at the time of treatment. In addition, insurance companies may not cover all medically and dentally necessary procedures. Coastal does not have a contract with your insurance company, only you do. Insurance companies do not guarantee payment until a claim is made. Therefore, estimates are merely estimates of what the insurance covers. This is true even with pre-authorizations. Since insurance coverage is a contract between you, your employer, and the insurance company, we remind you that any unpaid balances on the account will be your responsibility. We will assist you if you have questions about insurance delays or amounts, though we have found that insurance providers are more responsive to patients (their beneficiaries). Our policy at Coastal is that all outstanding balances be paid within 30 days of a receipt of statement. If the fee is not completely paid, then it will gain a 1.5% monthly (18% annually) interest rate.

6 If a patient does not have insurance, then we require full payment of fees at the time of treatment unless other arrangements have been made (e.g. with the CareCredit financing program). Payment may be made in the form of cash, credit card (Visa, MasterCard, American Express, Discover), check, or debit card. If we have not received payment or contact from you within 90 days after treatment, then we reserve the right to take further action with a collection agency. Parent Participation Unlike many other pediatric dental offices, we welcome parents to our treatment area so they can sit with their child during cleaning appointments. Because of limited space, we ask that only one adult accompany the child back to the treatment area for operative (fillings and crowns) appointments. Parents can sit nearby as a silent observer so cooperation and trust can develop between your child and our doctors. This allows children to communicate directly with our dentist and team without distractions and safety concerns. We find that there are times when a child s dental experience can be enhanced when a parent is absent from the treatment area, especially as the child grows older. We may ask a parent to wait in our office lobby so their child can communicate more directly with our dentists and build a relationship of trust with them. Coastal Pediatric Dental & Anesthesia does not allow parents to remain in the operating rooms during treatment under IV sedation and general anesthesia. Cell phones are discouraged in our treatment area because conversations carried by others may distract your child, cutting into the line of communication with them and our dentists. If you need to use your cell phone, please feel free to step outside to take the phone call. Due to patient privacy concerns, please do not record photo/video in the treatment areas. Our goal is to give your child a safe, positive dental experience at Coastal Pediatric Dental & Anesthesia. Please call our office should you have any questions or concerns. Patient Name: Bill Party Name: (Please Print) Bill Party Signature: Date:

7 Pediatric Dentistry Consent For Dental Examination, Cleaning, Radiographs, Fluoride Treatment, Patient Management Techniques, Restorative Dentistry, and Acknowledgment of Receipt of Information We recognize the exceptional privilege that we enjoy as specialists in pediatric (children s) dentistry and anesthesia. Coastal Pediatric Dental & Anesthesia is honored to be your partner in achieving your family s oral health goals. Your child's welfare and safety are of utmost importance to us. State Law requires health professionals to provide their prospective patients with information regarding the treatment or procedures they are contemplating. Please read this form carefully and ask about anything you do not understand. We will be pleased to explain it. It is our intent that all professional care delivered in our dental office shall be of the best possible quality we can provide. Providing high quality care can sometimes be made very difficult, or even impossible, because of the lack of cooperation of some patients. All efforts will be made to obtain the cooperation of pediatric dental patients by the use of warmth, friendliness, persuasion, humor, charm, gentleness, kindness and understanding. There are several behavior management techniques that are occasionally used by pediatric dentists to gain and encourage the cooperation of child patients and prevent patients from causing injury to themselves due to potentially harmful movements. The more frequently used pediatric dentistry behavior management techniques are as follows: 1. Tell-show-do: The dentist or assistant explains to the child what is to be done in simple terms and then shows the child what is to be done by demonstrating with instruments on a model or the child s or dentist s finger. Then the procedure is performed in the child's mouth as described. Praise is used to reinforce cooperative behavior. 2. Positive reinforcement: We always use this technique, which rewards the child who displays any positive behavior. Rewards include compliments, praise, a pat on the back, a hug or a prize. 3. Voice control: The attention of the child is gained by changing the tone or volume of the dentist's voice (caring, warm, but firm). 4. Stabilization: The assistant will always comfort our patient by holding their hands. The dentist or the assistant may need to gently stabilize the child's head and/or control leg movement to prevent any sudden movement. On rare occasions, it may be necessary to use passive restraints such as a papoose board. In addition, Coastal Pediatric Dental & Anesthesia is fortunate to have the facilities and dedicated anesthesia support to offer a full range of pharmacologic adjuncts to dental care. These services may be offered both in our practice and at certain local hospitals and surgical centers. These options include: 5. Sedation: Sometimes drugs are used to relax a child who needs it. These drugs may be administered orally or via inhalation (nitrous oxide). The child does not become unconscious, and should be responsive and may remember and understand what is occurring. You will be further informed and your specific consent obtained if we feel there is a need for sedation. 6. General Anesthesia: The dentist performs the dental treatment with the child anesthetized in either our or the hospital s operating rooms. An anesthesiologist will be present to deliver the anesthesia care. You will be further informed and your specific consent will be sought if there is a need for general anesthesia. If you believe that sedation or anesthesia will be necessary, please do not hesitate to let us know.

8 I request and authorize Coastal Pediatric Dental & Anesthesia, the practice of Drs. Kari Cwiak and Jonathan Wong, and other health care professionals on staff to perform or assist in the performance of the following but not necessarily limited to: Examination and radiographs (X-rays) as determined by the dentist. Cleaning of the teeth and application of topical fluoride. Application of plastic sealants to the fissures or grooves of the teeth. Administration of local anesthetics. Treatment of diseased or injured teeth with dental restorations (fillings, crowns and pulpotomies). Removal (extractions) of one or more teeth. Treatment of diseased or injured oral tissues (hard and/or soft). Replacement of missing teeth with space maintainers and/or dental prosthesis. Postponing or delaying treatment at this time if unable to complete treatment with the aforementioned behavior management techniques. I understand that unforeseen conditions or circumstances may arise during the course of the above-described procedure or treatment. Hence, I consent to and authorize the performance of any care, procedure, or treatment not specified above that the dentist reasonably believes necessary or advisable as a result of these unforeseen events. The purpose of the above is to maintain dental health and we anticipate that result. No guarantees or assurances can be made as to the results that may be obtained. Bleeding, swelling, discomfort, and bruising can occur after any dental procedure. However, not completing necessary dental treatment can result in abscess, infection, pain, fever, swelling and substantial risk to the developing permanent teeth. I consent to the administration of local anesthetic that the dentist deems necessary, and/or nitrous oxide. I understand that the risks involved with the administration of local anesthetics may also be characterized by excitation, depression, nervousness, dizziness, blurred vision, tremors, drowsiness, convulsions (seizures), unconsciousness and possibly cardiac/respiratory arrest. Allergic reactions may occur which may be characterized by skin eruptions, itching, and swelling. I understand that the alternative of not using local anesthetic could cause a great deal of discomfort and pain. The risk of this alternative could be emotional damage and psychological trauma. I understand that should the child become uncooperative during dental procedures with movement of the head, arms and/or legs, dental treatment cannot be safely provided. During such movements, it may be necessary to use behavioral management techniques, including stabilization as described previously. My signature below signifies I authorize the use of stabilization techniques, when deemed absolutely necessary to avoid possible injury to the child. I understand that I may refuse to consent to any and all treatment. However, refusal of medically necessary treatment or requests/refusals that would cause treatment to be below the standard of care or present a risk to you or the patient may result in termination of the dentistpatient partnership. I certify that I have read and understand the above. I accept the risk of substantial and serious harm, if any, in hope of obtaining the desired beneficial results of this treatment or procedure. I acknowledge that the dentist has explained all of the above to me in a thorough and comprehensible manner, and that my questions about my treatment and its attendant risks have been answered to my satisfaction. Patient s Name: Date of Birth: / / Signature: Relationship to Patient : Date: Time: Witness (Signature and Print):

9 NOTICE OF PRIVACY PRACTICES PARENT/GUARDIAN DISCLOSURE FORM This form is required by the Health Insurance Portability and Accountability Act of 1996 in compliance with the privacy regulation effective for this on September 1 st, 2017, only if our of@ice wishes to use or disclose your protected health information for any other purpose not clearly spelled out in our of@ice Privacy Policy Notice. To use or disclose your protected health information in such cases, our of@ice must receive prior written authorization from you. Our of@ice will condition treatment, payment, enrollment or eligibility for bene@its on whether you sign this authorization. The purpose for which our of@ice is requesting your authorization is to diagnose and complete treatment. The information to be disclosed would include your protected health information (PHI). The information may be disclosed to, but not limited to, laboratories, hospitals, insurance companies, medical and dental referrals, and other health care professionals. This form also authorizes the use of photography as a diagnostic tool. By agreeing to this authorization, you understand that the potential for information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by the privacy regulation of HIPAA. You also understand that you are entitled to receive a copy of this authorization form. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES **You May Refuse to Sign This Acknowledgement** I,, have received and reviewed this of@ice s Notice of Privacy Practices. Parent / Guardian Name In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of the protected health information, (PHI). The individual is also provided the right to request con@idential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual s of@ice instead of the individual s home. I wish to be contacted in the following manner: (check all that apply) Home Phone: Work Phone: Mobile Phone: Message with Detailed Information Leave Call-Back Number ONLY Message with Detailed Information Leave Call-Back Number ONLY Message with detailed information Receive Text Messages. Written Communication: Okay to Send to My Home Address: Okay to to this Okay to Fax to this Number: Other: (Please note that Coastal cannot ensure end user security of your , text messages, or e-faxes.) How do you prefer Coastal Pediatric Dental & Anesthesia addresses you? Patient s Name: Patient s or Parent s/guardian s Signature: Date:

10 Authorization for Release / Use of Protected Health Information In the Form of Photos, Radiographs, and Electronic Images Your photos and x-rays are part of your diagnostic and clinical record and are considered to be protected health information under federal HIPAA Privacy Laws. We make use of radiographs (x-rays), photographs, and digital images. These images may be used for diagnosis, documentation, reference, teaching, and research publication. Some cases that present exceptional results, and/or particularly remarkable smiles, and/or interesting situations may be utilized for demonstration, education or advertising to potential and existing patients in our of@ice either in print media, social media, television, on digital media and/or on our webpage. In some instances, you may be recognizable in some of these images. By signing this form, you are authorizing us and releasing us from any liability resulting from the use/release of such images. Your authorization and release to use images will in no way affect the quality of your results in our of@ice. If you do not wish Coastal Pediatric Dental & Anesthesia to use such images, please initial your preferred privacy options below. We always do our best to provide exceptional dentistry to all patients. I DO NOT authorize the use of my images where my/my child s face is identi@iable I DO NOT authorize the use of my images where only my/my child s teeth are identi@iable I DO NOT authorize the use of my radiographs (identifying information removed) The purpose of this request to release and/or disclose the PHI described above is for personal reasons. I understand that I have the right to revoke this Authorization, in writing, at any time by notifying the of@ice above. Such revocation will not affect actions taken by the requesting person prior to the date they received the written revocation. I also understand information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and will no longer be protected by this rule. I understand that my health care provider cannot condition treatment on whether I sign this Authorization. This Authorization will expire at such time that: I determine that I no longer wish for my/my child s images to be used and I revoke this authorization in writing; or The following date: (within one year of current date). Patient Name(s): Signature of Patient or Guardian: Date: