Chris Munkel Patient Information Form

Patient Information

Patient’s Name

Email:

Work Phone:

Cell Phone:

Home Phone:

Home Address: Street

City

State

Zip

Social Security#

Birth Date:

Employer:

Occupation:

Parent if minor

Parent Name:

Parent Employer :

Phone:

Physician :

Phone:

Emergency Contact:

Phone:

Whom may we thank for referring you?

Who is financially responsible for your account?

How do you spend your free time?

Dental Insurance Information

Name of Policy Holder:

Policy Holder’s SSN/ID#

Group #:

Employer Name:

Policy Holder’s DOB:

Insurance Company:

Insurance Company Phone:

Policy Address: Street

City

State

Zip

HIPAA Consent and Notice of Privacy Practices

Purpose of Consent: By signing this form, you consent to our use and disclosure of your protected health information to carry our treatment, payment activities and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide to sign this consent. Our notice provides a description of our treatment, payment activities, healthcare operations and of the uses and disclosures we may make of your protected health information.

I authorize the release of my dental information to:

Name:

Relationship:

ACKNOWLEDGEMENT

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 healthcare operations.

Signature

Date:

Oral Cancer Screening

Our practice strives to provide important enhancements in oral health care for our patients. We are concerned about oral cancer and look for it in all at risk patients. One person dies every hour in the United States from oral cancer. 25% of oral cancer victims have no lifestyle risk factors.

Oral cancer risk factors include, but are not limited to people over 40 years old, tobacco use, chronic alcohol consumption and oral HPV infection.

We find that using Oral ID along with visual oral cancer examinations improves our ability to identify suspicious areas that may have been missed during the conventional examination. Early detection of pre cancerous tissue can minimize or eliminate the potentially disfiguring effects of oral cancers and possibly save your life.

Dental insurance might not cover the Oral ID exam. However, this office is happy to verify your coverage. The fee for this enhanced examination is $20

Yes. I authorize the clinician to perform the Oral ID exam along with the standard oral cancer examination. I accept financial responsibility for this enhanced exam.

Signature

Date:

No. I would prefer not to have the Oral ID exam at this time.

Signature

Date:

FINANCIAL & CANCELLATION AGREEMENT

IF YOU HAVE DENTAL INSURANCE:

Your insurance is a benefit to you. As a courtesy, our staff will coordinate your dental benefits and send claim forms along with any required correspondence to your insurance carrier. The information our staff receives from your insurance carrier regarding your dental benefits is an estimate and is not guaranteed until it has been reviewed and authorized by a professional representative from your insurance carrier. Services not covered by your insurance carrier due to waiting periods, or any other reason(s) specified by your insurance carrier, are YOUR RESPONSIBILITY and are to be paid IN FULL at the time services are rendered, or upon rejection of your claim.

Dental benefits are based upon a contract made between you and your insurance company. If you have any questions regarding your dental benefits please contact your insurance company directly. Dental benefit plans will NEVER pay for all dental care expenses. It is only meant to assist you.

WE DO NOT ACCEPT SECONDARY INSURANCE due to numerous limitations placed by insurance carriers regarding coordination of benefits and several policies. Your portion is due regardless of the secondary coverage. You are responsible for submitting any claims and necessary correspondence to your secondary insurance carrier for reimbursement.

IF YOU DO NOT HAVE DENTAL INSURANCE:

Payment is due in full at the time services are rendered. Our office accepts Visa, MasterCard, Discover, American Express, Care Credit, Debit cards, Cash and Personal checks.

CANCELLING AND RESCHEDULING PATIENTS

Broken appointments are a significant contributor to rising healthcare costs, and we make every attempt to remind you of your upcoming appointments by E-mail, Text message, and Telephone. Please notify our office in advance (at least 24 hours prior to your scheduled appointment) if you need to cancel or reschedule your appointment(s).

Please review our office policies:

*I agree to pay any balance at the time of services rendered.

I understand that not all services and fees are fully covered by my insurance carrier.

I am responsible for any non-covered procedures, unpaid balances, deductibles or co-pays.

It is MY responsibility to understand MY dental insurance policy and the coverage they provide.

At no time will inappropriate language be tolerated while on the premises or by phone to any staff member.

Such behavior could justify cause for termination of provider-patient relationship. A letter will be sent to the patient to notify of termination.

There will be a $65 charge for missed appointments not cancelled within 24 hours.

(If your appointment falls on a Monday, notice must be given by end of regular working hours on the previous Thursday.)

I have read and fully understand this Financial & Cancellation Agreement, and I agree to the terms listed above.

Signature

Date:

Patient Information

Dental Insurance Information

Dental history

HIPAA Consent and Notice of Privacy Practices

ACKNOWLEDGEMENT

Oral Cancer Screening

FINANCIAL & CANCELLATION AGREEMENT

CANCELLING AND RESCHEDULING PATIENTS