Dental Registration and History

1. PATIENT INFORMATION

  M   F

2. EMPLOYER / SCHOOL

3. EMERGENCY CONTACT

4. INSURANCE INFORMATION

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


and assigned 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 in 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 to completed or one year from the date signed below.

5. DENTAL HISTORY

  Yes   No   if yes please describe
Do you feel numbness, swelling, or any other sensitivity?   Yes   No   if yes please explain  
 

Dental Registration and History Page 2

6. HEALTH HISTORY


Have you ever taken any of the group of drugs collectively referred to as “Fen-Phen?” These include combinations of Ionimin, Adipex, Fastin (brand names of phentennlne), Pondimin (fenfluramine) and Redux (dexfenfluramine)   Yes   No
Place a mark on “yes” or “no” to indicate if you have had any of the following:
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     Yes     No   If yes due date:Are you nursing?   Yes     No

7. MEDICATION & ALERGIES


Are you allergic to any of the following?     Yes    No
If yes please circle: Aspirin, Barbiturates (Sleeping pills), Codeine, Iodine,
Latex, Local Anesthetic, Penicillin
Aspirin Barbiturates (Sleeping pills) Codeine Iodine Latex Local Anesthetic Penicillin Any other allergies?    Yes    No

8. UPDATES (for future visits)


Changes to medical history


Changes to medical history


PATIENT HIPAA CONSENT FORM

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:



• Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)
• Obtaining payment from third party payers (e.g. my insurance company);
• The day-to-day healthcare operations of your practice.



I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.


I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.


Date:








Mitchell Dental
7500 E Angus Dr, Suite 2
Scottsdale, AZ 85251

January 30, 2014 AM

Financial Policy

Thank you for choosing our office for your dental healthcare. We are unconditionally committed to provide you with the best in preventative approaches as well as the highest standards of treatment and dental procedures for solutions to your dental problems.



Our office does require your social security number for our records. Please understand that other than your insurance company (if applicable) all of your patient information is strictly confidential. To have your services comfortably affordable please review the following financial policies and
select the type of account that best suits your needs:



Payment is expected on the day services are rendered (initials____)

We accept Visa, MasterCard, Discover, and American Express.

Care Credit Financing Available (initials____)

Our patient coordinator will be happy to assist you with the application process.



Understanding Insurance Benefits

As a courtesy for our patients with most dental insurance plans, we will happily submit dental claims to your insurance company for services rendered. Insurance companies are by Arizona regulations to pay your claims within 30 days of having been submitted. The estimated portion of your non-covered expenses will be due at the time of services. Please be advised that your estimated out of pocket portion is only an approximation, we can never guarantee what an insurance company will and will not cover.Since your contract is between you and your insurance company, any balance not paid in 45 days will be your responsibility. We will do everything possible to insure that the insurance company pays for any and all eligible expenses. By you signing this policy, you are giving us permission to bill your insurance company for services rendered and allow us to review your treatment plan with them. You understand completely that if your insurance company does not cover said services, for any reason, you are FULLY responsible.
Our patient coordinator is very knowledgeable in all areas of our financial policy and will be
more than happy to assist you with solutions to your financial needs.

We do expect you to show up for your scheduled apportionments. If you do need to reschedule,
we require 48 hours notice. If this notice is not given, or an appointment is just missed you may
be assessed a $50.00 missed appointment charge.




April 20, 2017 updated