Please Print & Complete To Bring To Dental Appointment
PATIENT INFORMATION: (CONFIDENTIAL)
Name_______________________________________________SS#(Must Have)______________________________DOB(Must Have)___________________
Home Phone____________________________________ Cell Phone ___________________________________ Work Phone ___________________________
City _________________________________________________________________ State ______________________________ Zip Code ______________________
Circle Appropriate Option: MINOR SINGLE MARRIED DIVORCED WIDOWED SEPARATED
If Student, Name of School/College: ____________________________________________________________________________________________________
Patient or Parent/Guardian’s Employer ________________________________________________________________________________________________
Business Address _______________________________________________________________________________________________________________________
Spouse or Parent/Guardian’s Name ____________________________________________________________________________________________________
Whom may we thank for referring you? ________________________________________________________________________________________________
Person to contact in case of emergency? ________________________________________________Number______________________________________
Person Responsible for this Account ___________________________________________________________________________________________________
Relationship to Patient _______________________________ Work Phone __________________________ Cell Phone _____________________________
Driver’s License # _____________________________________ D.O.B. ______________________ Employer ________________________________________
For your convenience, we offer the following methods of payment. Please circle the option you prefer.
Payment is due in full at each appointment. CASH PERSONAL CHECK CREDIT CARD
Name of Insured ______________________________________________________________ Relationship to Patient________________________________
D.O.B(Must Have). _____________________________ SS#(Must Have)____________________________________ Date Employed ________________
Name of Employer _________________________________________________________________ Work Phone ______________________________________
Address of Employer _____________________________________________________City___________________________Zip____________________________
Insurance Company _____________________________________________________________________________________________________________________
Address __________________________________________________________________________________City ____________________ Zip____________________
ADDITIONAL INSURANCE INFORMATION:
Name of Insured_________________________________________________________Relationship To Patient___________________________________________
DOB______________________________ SS #___________________________________ Date Employed __________________________________________________
Name of Employer_________________________________________________________Work Phone_____________________________________________________
Address of Employer_______________________________________________________City _______________________ State_________________ Zip___________
ID/Enrollee/Subscriber # ________________________________________________________________________Group # ___________________________________
Address ___________________________________________________________________________________ City _______________________ Zip ___________________
PATIENT CONSENT FORM
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice you may obtain a revised copy contacting our office.
You have the right to request that we restrict our protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.
By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on you prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPPA)
The patient understands that:
Protected health information may be disclosed or used for treatment, payment or health care operations
The Practice had a Notice of Privacy Practices and that the patient has the opportunity to review this Notice
The Practice reserves the right to change the Notice of Privacy Policies
The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions
The patient may revoke this Consent in writing at any time and all future disclosures will then cease
The Practice may condition treatment upon the execution of this Consent.
This Consent was signed by: _______________________________________________
Printed Name – Patient or Representative
Relationship to Patient (if other than patient): _____________________________________________
In front of _______________________________________________________
______________________________ Printed Name – Practice Representative
We are a health centered dental practice. Thus, we are concerned with your total well-being, not just your oral health. An essential part of our approach is a thorough health history. Please fill out the health questionnaire, if you have not already, even if some of the questions may not seem relevant to your dental health. After completing and/or reviewing health history update, please give signature below. Thank you!
To avoid any misunderstandings regarding your dental insurance, we wish our patients to know that all professional services rendered are charged directly to the patient and that patients are personally responsible for payment of fees. We do not render services on the basis that the insurance companies will pay our fees unless a pre-determination of benefits has been established. We will assist you in filing all insurance forms. Payment is due when services are rendered unless other arrangements have been made. If you must change a scheduled appointment, please inform us as soon as possible. If we are not notified before 3:00 p.m. the working day prior to your appointment, then we may regrettably, charge your account.
I hereby authorize Dr. Rusty Riley to take radiographs, study models, photographs, or any other diagnostic aids deemed appropriate by Dr. Rusty Riley to make a thorough diagnosis of my dental needs. I also authorize Dr. Rusty Riley to prescribe any and all forms of medication, and perform any therapy that may be indicated and agreed upon.
I further authorize the release of any information, including the diagnosis and the records of any treatments or examinations rendered, to my insurance company or consulting professionals. The release to the insurance company is solely for the purpose of facilitating the billing and reimbursement directly to the dentist of insurance benefits under which I am entitled. I understand that responsibility for payment for dental services provided in this office for me or my dependents is mine, due and payable at the time services are rendered.
Patient and/or Patient Representative
Highland Village Dental Care Representative
Correct answers to the following questions will allow us to treat you on a more individual basis, providing the care appropriate for your particular needs.
Name_____________________________________________________________________________________ DOB _________________________________
Why are you now seeking dental treatment? _____________________________________________________________________________________________
Please answer each question. Circle yes or no. If in doubt, leave blank.
1. Are you in good health now? YES NO
2. Are you under the care of a physician? YES NO
3. Have you ever been hospitalized or had a serious illness? YES NO
If yes, explain _____________________________________________________________________________________________
4. Have you ever had excessive bleeding following an extraction, or do cuts take longer to heal? YES NO
5. (Women) Are you pregnant? If so, give due date ________________________________ YES NO
6. Do you use tobacco in any form? If yes, how much ______________________________ YES NO
7. Do you use alcoholic beverages (more than 2 drinks per day)? YES NO
8.Do you have or have you ever had any of the following? If yes, please circle
Tire easily, weakness
Marked weight change
Eruptions (rash) hives
Changes in skin color
Loss of hearing
Ringing in ears
Sputum production (phlegm)
Cough up blood sputum
Family History of Diabetes
Shortness of breath
Swelling of Ankles
High blood pressure
Congenital heart disease
Mitral valve prolapse
Artificial heart valve
Change in appetite
Black, bloody, pale stools
Increase of urination(night)
Burning on urination
Tumors or growths
9. Are you ALLERGIC or have you ever experienced any reaction to the following? If so, please circle.
Local anesthetics (novocaine, etc.)
Other (please list) ______________________________________________________________________________________________________
10. Are you taking any of the following? If so, please circle.
Blood pressure medication
Antihistamines/allergy or cold drugs
Insulin/other diabetes drugs
Digitalis/other heart medications
If any of the above list is circled, please list NAME of medication and DOSAGE below:
____________________ ____________________ ____________________ _____________________
____________________ ____________________ ____________________ _____________________
____________________ _____________________ _____________________ _____________________
11. Is there any disease, condition, or problem not listed above that you think we should know, about or is there any activity your doctor says
you can not do? If so, explain ______________________________________________________________________________________________________
12. Physician’s Name ________________________________________________________________________Phone____________________________________
13. Have you ever had any serious trouble associated with previous dental treatment?_______________________________________________
14. Does dental treatment make you nervous? Please Circle One. No Slightly Moderately Extremely
15. Date of last dental visit ______________________________________________________________________________________________________________
16. Have you ever been treated for periodontal disease (gum disease, pyorrhea, trench mouth)?______________________________________
If so, when? ___________________________________________________________________ Specialist’s Name _____________________________________
17. Do you have or have you EVER had any of the following? If so, please circle.
Bleeding, sore gums
Unpleasant taste/bad breath
Frequent blisters, lips/mouth
Swelling/lumps in mouth
Ortho Treatment (braces)
Difficulty Opening or Closing Jaw
Sensitive to hot
Sensitive to cold
Sensitive to sweets
Sensitive to biting
Shifting of Teeth
Change in Bite
Do you use any of the following? If so, please circle.
How often do you brush_________________
Brush is: (Please circle) SOFT MEDIUM HARD
To the best of my knowledge, all of the preceding answers are true and correct.
If I ever have any change in my health or change in my medication, I will inform the dentist at my next appointment.
Signature of Patient, Parent, or Guardian ____________________________________________________________________ Date________________________
Written Financial Policy
Thank you for choosing Ralph P Riley, DMD aka Dr. Rusty Riley. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.
You may choose from:
-Visa, MasterCard, American Express, Discover Card, Flex Plan Card
-Care Credit, A convenient monthly payment option from Care Credit Health Care Credit Card
-Allows you to pay overtime with no annual fees or pre-payment penalties
Rusty Riley DMD requires payment PRIOR to the completion of your treatment. If you choose to discontinue care before treatment is complete, your refund will be determined upon review of your case.
We accept payment in thirds for treatments over $1000.00. For plans requiring more than THREE appointments, alternative payment arrangements may be provided.
For patients with dental insurance we are happy to work with your carrier to maximize your benefit and directly bill your insurance provider for reimbursement for your treatment.
A fee of $25 is charged for patients who miss or cancel more than TWO times in a calendar year without a 24-hour notice.
Rusty Riley DMD charges $30 for returned checks or debit card payments.
Once Insurance pays, if applicable, or if insurance is denied, patient is fully responsible for their balance. If patient's bill is turned over to a collections agency, the patient will be responsible for any collection/attorney's fees as 30% added to my total balance.
If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need.
Patient, Parent or Guardian Signature______________________________________________________________Date________________
Patient Name (Please Print)_________________________________________________________________________Date________________
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORTMATION.
PLEASE REVIEW IT CAREFULLY.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This notice takes effect________________ and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:
Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to any purpose. If you give us an authorization, you may revoke it in writing at any time. You revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.
To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.
Required by Law: We may use or disclose your health information when we are required to do so by law.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we responsibly believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety of the health or safety of others.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of information of patient under certain circumstances.
Appointment Reminders: We may use disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters)
Access: You have the right to look at or get copies of your health information , with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-basted fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of the Notice. If you request copies, we will charge you a fee for each page, as well as a fee per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.
Disclosure Accounting: You have the right to receive a list of instances in which we are or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations, and certain other activities, for the last 6 years, but not before April 2006. If you request this accounting more than once in a 12 month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.
Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.
Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us.
If you are concerned that we may have violated our privacy rights, or disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of you r health in formation or to have us communicate with your by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.
We support your right to the privacy of your information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
Contact Person: Jessica Lauren Jenkins
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
SECTION A: PATIENT GIVING CONSENT
D/O/B_______________________________________________SOCIAL SECURITY NUMBER____________________________________________________________________
SECTION B: TO THE PATIENT – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY
Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and health care operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected heath information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notices, at anytime by contacting:
Contact Person: Jessica Lauren Jenkins
Right to Revoke: You will have the right to revoke this Consent at anytime by giving us written notice of your revocation submitted to the Contact person listed above. Please understand that the revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.
I, ______________________________________________________________________________________________, have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and health care operations.
If this Consent is signed by a personal representative on behalf of the patient, complete the following:
Personal Representative’s Name________________________________________________________________________________________________________________________________________________
Relationship to Patient____________________________________________________________________________________________________________________
Revocation of Consent
I revoke my Consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations.
I understand that revocation of my Consent will not affect any action took in reliance on my Consent before you received this written Notice of Revocation. I also understand that you may decline to treat or continue to treat me after I revoked my Consent.
YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
*You May Refuse to Sign This Acknowledgement*
I, ___________________________________________________________________________, have been offered a copy of this office’s Notice of Privacy Practices.
For Office Use Only
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:
O INDIVIDUAL REFUSED TO SIGN
O COMMUNICATIONS BARRIERS PROHIBITED OBTAINTING THE ACKNOWLEDGMENT
O AN EMERGENCY SITUATION PREVENTED US FROM OBTAINTING ACKNOWLEDGMENT
O OTHER (PLEASE SPECIFY)