Summer Hill Dental Matthew W. Bayless DDS, PC 19750 State Highway 46 W., Suite 105 Spring Branch, TX 78070 Thank you for visiting Summer Hill Dental. We want your visit to be pleasant and comfortable. Please help us by completing this form. Patient Information Name Address LAST FIRST MIDDLE INITIAL NICKNAME STREET Employer Driver s License # Birthdate CITY STATE ZIP Phone: Home ( ) Social Security # May we contact you at work? Yes No Work ( ) Mobile( ) Male Female E-mail address Emergency: Name Phone ( ) Insurance ~ Primary Dental Carrier Subscriber Name Social Security # DOB Employer Insurance Co. Group# Insurance ~ Secondary Dental Carrier Subscriber Name Social Security # DOB Employer Insurance Co. Group # Insurance Authorization Statement (Sign & Date) Married Divorced Single I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs and dental treatment. I hereby authorize the Dental Office to administer such medications and perform such diagnostic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the medical history are correct to the best of my knowledge. Signature Date If Patient is under 18 Responsible Party Address STREET Relation to Patient CITY STATE ZIP Telephone ( ) 1
Summer Hill Dental Matthew W. Bayless, DDS 19750 SH 46 W #105, Spring Branch, TX, 78070 (830)438-2193-phone How did you hear about us? OCCUPATION CHIEF CONCERN HISTORY OF CHIEF CONCERN PREVIOUS DIAGNOSES Smoke? Packs/day #years Drink coffee/cola? How much/day? Are you currently under medical care for any reasons? If yes, please explain: Please list all medical doctors that you currently see: Please list all medications that you are now taking: PAST MEDICAL HISTORY: (Please check ALL that apply) Conditions Allergies Aspirin Codeine Dental Anesthetics Erythromycin Latex Metals Penicillin Sulfa Tetracycline Other Pre-med-Amoxicillin Pre-med-Clindamycin Alcohol Abuse Allergies Anemia Arthritis Asthma Blood Disease Blood Transfusion Cancer Chemotherapy Congenital heart disease Cortisone medication Diabetes Difficulty Breathing Drug Abuse Emphysema Epilepsy If Female: Excessive Bleeding Y N Are you taking Birth Control Pills? Are you pregnant? If yes, # of weeks Are you Nursing? Facial Surgery Fainting Spells Fever Blisters Frequent Headaches Glaucoma HIV / Aids Heart Attack Head Injury Heart Disease Heart Murmur Heart problem Heart Surgery Heart Valve Replace. HPV Hepatitis A / B / C High Blood Pressure High cholesterol Joint Replacement Kidney Disease Liver Disease Low Blood Pressure Mental Disorder Mitral Valve Prolapse Pace Maker Radiation Therapy Rheumatic Fever Rheumatoid Arthritis Sexually Transmitted Disease Shingles Sinus Proble Sleep Apnea Stroke Stomach Problems Thyroid Problems Tuberculosis Tumors Ulcers Immune system disorder Mononucleosis (EBV) Frequent sore throats Tonsillitis Tonsillectomy Adenoidectomy Ear pain Hearing problem Headaches Head pain Neck pain Back pain Head, face, neck trauma Muscle spasms/cramps GERD Menopause Herpes Fibromyalgia Anxiety Depression Psychiatric treatment 2
Summer Hill Dental Matthew W. Bayless, DDS 19750 SH 46 W #105, Spring Branch, TX, 78070 (830)438-2193-phone PHYSICAL CONDITIONS: Weight Height ft. inches Do you suffer from any type of sleep problems? Yes / No (if No then skip to last page to sign and date form) SLEEP DISORDER SYMPTOMS: (Please circle any conditions that apply) Loud snoring Difficulty initiating sleep Delayed sleep onset Excessive daytime sleepiness Unrefreshing sleep Nightime choking Awaken gasping Frequent sleep arousals Frequent awakenings Insomnia Esophageal reflux HISTORY: Heartburn Drooling Frequent nocturnal urination Limb movement Restless legs Sleep paralysis Cataplexy/muscle rigidity Nightmares/terrors Sleep hallucinations Crying spells Depression EPWORTH SCALE: This questionnaire tells us how likely you are to doze off or fall asleep in the following situations, in contrast to just feeling tired. Your answers refer to your usual way of life in recent times. Even if you have not experienced some of these things recently, estimate how they would affect you. Use the following scale to choose the most appropriate number for each situation. 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing 0-9 Congratulations, you are getting enough sleep! 10-15 Possibly sleepy, may consider seeking medical attention. 16 and up Too sleepy, seek OSA treatment Have you had a weight change greater than 5 pounds in the last year?... NO / YES (if yes then answer appropriately) Gained lbs Lost lbs Frequent panic attacks Anxiety Difficulty concentrating Memory loss Night sweats Sleep walking Sleep talking Teeth clenching Nocturnal teeth grinding SITUATION CHANCE OF DOZING Sitting and reading Watching Television. Sitting inactive in public e.g. theater or meeting... As passenger in a car for an hour without a break.... Lying down to rest in the afternoon when able.. Sitting and talking to someone.. Sitting quietly after lunch without alcohol In a car stopped momentarily in traffic Do you have difficulty breathing through your nose at night?...yes NO Have you ever been treated for difficulty breathing through your nose?...yes NO If you awaken during the night, is it difficult to fall back asleep?...yes NO During an average night, how many times do you awaken? 1 2 3 4 5 6 7 8 On the average, how many hours do you sleep a night? 1 2 3 4 5 6 7 8 9 10 TOTAL Have immediate family members had sleep disorders?.....yes NO Do you have difficulty finding the energy to do your daily activities?...yes NO 3
Summer Hill Dental Matthew W. Bayless, DDS 19750 SH 46 W #105, Spring Branch, TX, 78070 (830)438-2193-phone Circle your usual sleep position or positions.. back side stomach varies How often do you consume alcohol? never once/week several times/week daily How often do you consume alcohol within two hours of bedtime?... never once/week several times/week daily Do you frequently wake up in the morning with a headache or get one shortly after awakening?...yes APNEA PATIENTS Have you ever had a sleep study?...yes NO Did you receive a diagnosis of obstructive sleep apnea?...yes NO If yes, name of doctor making the diagnosis If yes, specialty of health care provider making the diagnosis? If yes, what was your Apnea-Hypopnea Index? Name and location of Sleep Lab Has a CPAP (Continuous Positive Airway Pressure) Device ever been recommended? YES If you answered yes and found you could not tolerate it, circle the reasons below: Mask Leaks Improper mask fit Discomfort from straps/ headgear Bloated feeling Disturbed sleep from device noise CPAP restricted movements CPAP ineffective Pressure on upper lip Tooth discomfort Latex allergy Claustrophobic associations Disturbed bed partner s sleep Worsened sleep quality Other Circle or itemize other therapies performed to help your sleep apnea: Exercise Palatal surgery Nasal surgery Maxilla surgery Tongue surgery Smoking cessation Weight loss NO NO Tongue retaining device Mandibular advancement oral device Other Is there anything else that may be helpful for the doctor to know? Treatment Authorization I authorize and give consent to perform dental services agreed between doctor and patient and/or parent or guardian to be necessary or advisable including the use of local anesthesia and other medication as indicated. I certify to the above statements regarding my medical condition. I authorize Dr. Bayless to correspond with my health care providers. Payment for all treatment and services rendered are my responsibility. PATIENTS SIGNATURE If patient is a child or requires a guardian: PARENT/GUARDIAN SIGNATURE DATE DATE 4
Summer Hill Dental FINANCIAL POLICY Thank you for choosing our office for your dental needs. Please understand that payment of your bill is considered part of your family s treatment. All patients must sign this policy before seeing the doctor. A copy of our financial policy will be given to you upon your request. Because each financial situation is different, we will provide a written treatment plan with estimated costs for your review. We request payment for all services rendered at the time of the visit. As a courtesy, we will file your insurance claims promptly, collecting your copayment or out-of-pocket fees. Our office requires 50% of your estimated co-payment for your appointment, to secure the necessary time needed for your dental treatment, at the time the appointment is made. ($50.00 per hour is non-refundable should you cancel or miss your appointment without a 48-hour notice). Your insurance is a contract between you, your employer, and the insuring company. We are NOT a party to that contract. Our relationship is with you. We cannot become involved with disputes with you and your insurer regarding deductibles, co-payments, covered charges and usual and customary charges. All charges are YOUR responsibility whether your insurance company pays or does not pay. The information they provide us regarding your coverage and eligibility is not guaranteed and the actual coverage provided may be a lesser amount than we expect. We will need to collect from you any difference between our fees and what your insurance actually remits. If we fail to receive payment from your insurance company within 45 days, you will be asked to remit the full amount due and negotiate directly with them for your reimbursement. To assist you in receiving this care, we offer several payment options. You many choose to pay by Cash, Personal Check or Major Credit Card. If you request alternate arrangements, the details must be arranged in advance. If a collection agency must get involved to collect payment, all collection agency fees will be paid by the patient. I authorized Dr. Matthew Bayless to release any information including the diagnosis and the records of any treatment or examination rendered to myself or family members during the period of such dental care to third party payers. I authorize and request my insurance company to pay directly to Dr. Matthew Bayless, insurance benefits otherwise payable to me. We emphasize that our relationship is with you. Our diagnosis of treatment is always in your best interest to become healthy and not based on what your insurance will or will not do for you. Broken Appointments: A specific amount of time is reserved especially for you and we strongly encourage all patients to keep their appointments. If you must change your appointment, we require at least 48 hours notice to avoid a $50.00 per hour fee for cancelled or missed appointments (emergencies are an exception). I have read the Financial Policy. I understand and agree to this Financial Policy. Signature Date 5
HIPAA OMNIBUS RULE PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims. Date: The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE. Please print name of Patient Legal Representative / Guardian Please sign Patient / Guardian of Patient Relationship of Legal Representative / Guardian Your comments regarding Acknowledgements or Consents: HOW DO YOU WANT TO BE ADDRESSED WHEN SUMMONED FROM THE RECEPTION AREA: First Name Only Proper Surname Other PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION: (This includes step parents, grandparents and any care takers who can have access to this patient s records): Name: Relationship: Name: Relationship: --------------------------------------------------------------------------------------------------------------------------------- I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, TREATMENT & BILLING INFORMATION VIA: Cell Phone Confirmation Home Phone Confirmation Work Phone Confirmation Text Message to my Cell Phone Email Confirmation Any of the Above I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED VIA: Cell Phone Confirmation Home Phone Confirmation Work Phone Confirmation Text Message to my Cell Phone Email Confirmation Any of the Above In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent. --------------------------------------------------------------------------------------------------------------------------------- Office Use Only As Privacy Officer, I attempted to obtain the patient s (or representatives) signature on this Acknowledgement but did not because: It was emergency treatment I could not communicate with the patient The patient refused to sign The patient was unable to sign because Other (please describe) Signature of Privacy Officer HIPAA made EASY All Rights Reserved 6