Little Rock Branch New Patient Form

Little Rock Branch New Patient Form
Patient Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you been at this address less than 3 years?*

YesNo
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Birth Date*

MonthDayYear
Date
Social Security #*
Email*
example@example.com
Whom may we thank for referring you to our office?*
Is the Patient Married?*

YesNo
Spouse's Name

First NameLast Name
Spouse's Social Security #
Spouse's Date of Birth

MonthDayYear
Date
Spouse's Work Phone

Area CodePhone Number
Spouse's Employer
Is Patient a Minor?*

YesNo
Responsible Party Information
Name of Responsible Party
Relationship to Patient
Responsible Party Social Security #
Birth Date

MonthDayYear
Date
Responsible Party Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is Patient Employed?*

YesNo
Employer Information
Employer
Work Phone

Area CodePhone Number
Occupation
Total Years Employed
I understand, that where appropriate, credit bureau reports may be obtained.
Signature (Parent's Signature if minor)

Dental Insurance Information
Does the patient(s) have dental insurance?*

yesno
Insured's Name
Insured's Soc. Sec/ #
Insured's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured's phone number

Area CodePhone Number
Insured's ID #
Insurance Company
Group #
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Insured's Employer
Do you have dual coverage?

yesno
Insured's Name
Insured's Soc. Sec/ #
Insurance Company
Group #
Phone Number

Area CodePhone Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured's Employer
Are you able to take a photo or scan in your insurance card?

yesno
Front of Insurance Card
Back of Insurance Card
Front of Secondary Insurance Card (if applicable)
Back of Secondary Insurance Card (if applicable)

Authority to Treat
AUTHORITY TO TREAT

I give Bryan A. Austin, D.D.S., Brett Decoursey, D.D.S., Tara Scallion, D.D.S. and/or their qualified staff the authority to administer dental x-rays, local injections, anesthetics and if requested, nitrous oxide, in the subsequent treatment of my case. If I have a medical condition, such as mitral valve prolapse or an artificial joint that requires pre-medication, or if I am pregnant or think I may be pregnant, I acknowledge that it is my responsibility to inform and remind the doctor, assistant or hygienist at the beginning of each visit if ever I have a change in health. If I do not understand fully the dental procedure to be performed, it is my responsibility to inform Dr. Austin, Dr. Ivan, Dr. Hill or any staff member before proceeding.

PHOTOGRAPHS

I give my permission to Dr. Austin, Dr. Decoursey, Dr. Scallion, or any representative they may designate, to photograph me for diagnostic purposes and to enhance my medical record. I agree that these photographs will remain the property of Dr. Austin, Dr. Decoursey, and Dr. Scallion. I further authorize Dr. Austin, Dr. Decoursey, and Dr. Scallion to use these photographs for teaching purposes, to illustrate scientific papers, books, for use in general lectures, and promotion of this office. It is specifically understood that in any publication or use, I shall not be identified by name.

BROKEN APPOINTMENTS

48 hours notice of cancellation must be given to avoid a broken appointment charge of $25.00.

PAYMENT AGREEMENT

I understand that I am financially responsible for all charges, whether or not they are paid by insurance. I authorize the use of my signature on all insurance submissions. If I do not understand fully the approximate cost of the dental procedure being performed, it is my responsibility to inform Dr. Austin, Dr. Ivan, Dr. Scallion or any staff member, before proceeding. If I fail to pay my bill in a timely manner, I further agree to pay all necessary costs incurred in the collection of my account. I agree, in order for us to service your account or to collect any amounts that you may owe us, we may call you at any phone number associated with your account, including wireless numbers, which could result in charges to you. We may also communicate with you by sending text messages or e-mails to your wireless number or e-mail address. Methods of contact may include using a prerecorded/artificial voice and/or the use of an automated dialing device. These authorizations shall remain in effect until individually withdrawn by you in writing to our facility and/or any others to which authorization has been extended. I have read this disclosure and agree that your office or agent may contact me as described above.

BILLING CHARGES

A billing charge will be imposed on the unpaid balance of any procedure which has been posted to your account for 90 days. The minimum monthly charge on a balance is $0.50, or 18% annually. If any check is ever returned, I agree to pay a $25.00 returned check fee for each occurrence. I understand that if a collection agency is required to recover any unpaid balances on my account, the signee is liable for all collection agency fees incurred. This office reserves the right to refuse to treat any patient or potential patient. I have read, understand, and agree to the above policies.
Signature*
Date*

MonthDayYear
Date

Important Dental Information for our Patients
Understanding your insurance coverage can be quite challenging. Our goal is to assist you in maximizing your benefits. We care for patients from many different companies. Each company pays an insurance premium for specific coverage which fits the company budget. Each plan is slightly different in its covered services. We encourage you to become familiar with your policy exclusions, deductibles and required co-payments.

Our courtesy service to you includes:

1.     Filing your insurance and requesting payment of your benefit to our office.

2.     Electronically filing your insurance for short turnaround.

3.     Researching your dental insurance plan to advise you of benefits available to you.

4.     Re-filing your insurance a second time within 60 days.

5.     Following the American Dental Association guidelines for coding procedures and filing insurance.

Our expectations of you as the owner of the policy:

1.     Payment of fees not covered by your insurance plan at the time the service is delivered.

2.     Understanding that the insurance policy belongs to you and we have no leverage to obtain payment from your insurance carrier.

3.     Realizing that dental insurance policies restrict payment for some services, use restricted fee schedules (called Usual and Customary Rates) and exclude some procedures based on prior conditions or length of time on the plan. All restrictions are based on the premium paid for insurance, not our fees or recommended treatment.

4.     Understanding that the co-pay ESTIMATE quoted is only an ESTIMATE. This ESTIMATE is based on the percentages and information given to us by your insurance company. This ESTIMATE may possibly be affected by the following:
- the insurance company using their Usual and Customary Rates, not our fees.
- for a restoration on posterior teeth, many insurance companies still down grade composite restorations to the least expensive alternative treatment, which is usually amalgam, and then figure the benefit payable.
- any balance the insurance does not pay is my responsibility.
5.     THE PATIENT IS RESPONSIBLE FOR: understanding their insurance coverage and informing the office of any changes in your insurance coverage or employment.

6.     Taking responsibility for payment if the insurance company does not pay our office within 75 days.

7.     Any service that we provide cannot be billed to Medicare by either the patient or the dentist.

Austin Family Dentistry, P.A., is not responsible for mistakes any insurance company makes in statements made to us or any mistake in payment to us. Thank you for your cooperation with your dental insurance coverage. Please sign the space below and have your insurance card ready for us to copy for our file.

I hereby authorize Austin Family Dentistry, P.A., to release to my insurance company information acquired in the course of my dental care. I hereby authorize benefits to be paid directly to Austin Family Dentistry, P.A. I understand I am responsible for any unpaid balance.
Signature of Patient, Parent/Guardian or Personal Representative*
Date*

MonthDayYear
Date
Type name of Patient, Parent/Guardian or Personal Representative*

First NameLast Name
Relationship to Patient*

Austin Family Dentistry Little Rock or Maumelle

11211 Cantrell Road, Suite 200, Little Rock, AR 72212

3201 Club Manor Dr. Suite A. Maumelle, AR 72113

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

Section A: Patient Giving Consent

{name}

{socialSecurity}

{address}

{homePhone} | {cellPhone}

{email}

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 healthcare 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 health 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 Notice, at any time by contacting:

Contact: Dania                    Telephone: 501-851-3262 Fax: 501-851-3766

E-mail: baustindds@aol.com

Address: 3201 Club Manor Drive, Suite A Maumelle, AR 72113

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that 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,{name} , have had   full opportunity to read and consider the contents

of this Consent form and your Notice of Privacy Practices. 1 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 heath care operations.
Signature*
Date*

MonthDayYear
Date
If this consent is signed by a personal representative on behalf of the patient, complete the following:*
Personal Representative Name
Relationship to the Patient
YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.
Include completed Consent in the patient’s chart.

Austin Family Dentistry Little Rock or Maumelle

11211 Cantrell Road, Suite 200, Little Rock, AR 72212

3201 Club Manor Dr. Suite A. Maumelle, AR 72113

ACKNOWLEDGEMENT OF RECEIPT OF

NOTICE OF PRIVACY PRACTICES

**You May Refuse to Sign This Acknowledgement**

I have reveived a copy of this office's Notice of Privacy Practices

{name}
Signature*
Date*

MonthDayYear
Date
For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgment could not be obtained because:



___                        Individual refused to sign

___                        Communication barriers prohibited obtaining the acknowledgement

___                        An emergency situation prevented us from obtaining acknowledgement

___                        Other (Please Specify

.

Austin Family Dentistry, PA. Little Rock or Maumelle

11211 Cantrell Road, Suite 200, Little Rock, AR 72212

3201 Club Manor Dr. Suite A. Maumelle, AR 72113

ICES

         ______________________________________________________________

THIS NOTICE DESCRIBES HOW   HEALTH   INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. 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 April 14, 2003 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 will use your Health Information within our office to provide you with the best dental care possible. 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 disclosure 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, cf 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 w* 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.
By signing below, you are acknowledging that you agree to The HIPAA consent for Austin Family Dentistry. You are also acknowledging that all information obatined in this Patient Paperwork form, in its entirety is true to your best known ability and nothing has been falsified, and you understand that falsifying medical forms and information is against the law and may be punishable by local state and federal law enforcement.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Little Rock Branch New Patient Form

Patient Information

Responsible Party Information

Employer Information

Dental Insurance Information

Dental History

Medical History

Authority to Treat

Important Dental Information for our Patients