Dental Registration and Patient Health History

Last
First
Middle Initial
()
()
          
City
State
Zip Code
                                            
              
              
        
                   
Last
First
Middle Initial
()
()
              
Last
First
Middle Initial
()
()

Page 2

TERMS AND CONDITIONS

We are committed to providing you with the best possible care. Our fees reflect our professional commitment to excellence. If you have insurance, we are happy to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our FINANCIAL POLICY.

All accounts are due and payable at the time of your visit (including your percentage after insurance coverage), unless satisfactory arrangements have been made with our front desk. We are pleased to offer a 5% discount for accounts paid in full at the time of service. Visa, MasterCard, or Discover Card are accepted, but no additional discount will be given, as we pay a credit card user fee.

On accounts which have established financial arrangements with our office, the payment is due upon receipt of the monthly statement. Any balance outstanding more than 90 days will accrue additional interest at a rate of 1.5% per month. There will be a minimum charge of $35 for any returned checks due to insufficient funds.

As a courtesy, we will file your insurance claims for you and assist in helping you receive your maximum benefits. It is your responsibility to verify with our office that we have your correct insurance information and to inform us if there are any changes with your provider. Remember, insurance reimbursement is a contract between you, your employer, and your insurance company. Ultimately, dental services are charged directly to you and you are personally responsible for all charges whether or not paid by insurance. This dental office cannot render services on the assumption that charges will be paid by an insurance company.

In order to use our time efficiently, keep our fees as low as possible, and best serve our patients, there may be a $50 charge for any missed appointments and/or appointments not cancelled 24 hours prior to the scheduled appointment time.

Assignment of Insurance and Release of Information:

(Name of Insurance Company)

and assign directly to Dr. Hagedorn all insurance benefits, if any, otherwise payable to me for services rendered. I authorize the use of my signature on all insurance submissions. Dr. Hagedorn may use my health care information and may disclose such information to 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 the related services.

I also understand that in order to collect my debt, my credit history may be checked through the use of my Social Security Number or any other information I have given you. I agree that in the event that either this office or I institute any legal proceedings with respect to amounts owed by me for services rendered, the prevailing party in such proceedings shall be entitled to recover all costs incurred, including reasonable attorney’s fees. I have read the above conditions and agree to their content.

CONSENT FOR TREATMENT

After explanation by Dr. Hagedorn, I hereby authorize the performance of dental services upon the named patients and his judgment in carrying out those necessary procedures. I also authorize and request the administration of any anesthetics and x-rays as may be deemed necessary and advisable by the doctor.

Page 3

DENTAL HISTORY

              
                   

Check if you have had problems with any of the following:

DENTAL PREFERENCES

              
              
              
              

ALLERGIES

MEDICATIONS

()

EMERGENCY CONTACT INFORMATION

()
()

Page 4

PATIENT MEDICAL/HEALTH HISTORY

              
    
    
    
    
              
              
              
              
              
              

I certify that the information I have provided is accurate and complete. I will not hold Dr. Hagedorn or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.


Notice of Privacy Practices

Summit Dental - Brad Hagedorn, DMD, PC

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 08/08/2011, 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 permitted by applicable law 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 anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your 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 reasonably 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 or 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 inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as email, voicemail messages, postcards, or letters).


PATIENT RIGHTS

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 make a 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-based 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 this Notice. If you request copies, a $25.00 fee may apply for staff time to 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 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 14, 2003. 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.


Acknowledgement of Receipt of Notice of Privacy Practices

Summit Dental – Brad R. Hagedorn, DMD, PC