LV SUBURBAN DENTAL ASSOCIATES AMERICAN DENTAL GROUP PC , AMERICAN ...

LV SUBURBAN DENTAL ASSOCIATES

AMERICAN DENTAL GROUP PC, AMERICAN DENTAL SPECIALTIES PC

1651 N. CEDAR CREST BLVD, STE 206

ALLENTOWN, PA 18104

PATIENT REGISTRATION

ID:

Chart ID:

First Name:

Patient Is:

Policy Holder

Responsible Party

Responsible Party (if someone other than the patient)

Last Name: Preferred Name:

First Name:

LLaasst t NNaammee: :

Address:

Address 2:

City, State, Zip:

Pager:

Home Phone: Birth Date:

Work Phone: Soc Sec:

Ext:

Cellular:

Drivers Lic:

Middle Initial: Middle Initial:

Responsible Party is also a Policy Holder for Patient

Primary Insurance Policy Holder

Patient Information

Address:

Address 2:

City:

State / Zip:

Secondary Insurance Policy Holder Pager:

Home Phone:

Work Phone:

Ext:

Cellular:

Sex: Birth Date:

Male Other

Female Age:

Marital Status: Soc. Sec:

Married

Single

Divorced Drivers Lic:

Separated Widowed

E-mail: Section 2

Employment Status:

Full Time

Part Time

Retired

I would like to receive correspondences via e-mail. Section 3

Additional Comments:

Student Status:

Full Time

Part Time

Medicaid ID:

Pref. Dentist:

Employer ID:

Pref. Pharmacy:

Carrier ID:

Pref. Hyg.:

Primary Insurance Information Name of Insured: Insured Soc. Sec: Employer:

Relationship to Insured: Self Insured Birth Date:

Ins. Company:

Address:

Address:

Address 2:

Address 2:

City,State,Zip: Rem. Benefits:

.00 Rem. Deduct:

City,State,Zip: .00

Secondary Insurance Information Name of Insured:

Relationship to Insured: Self

Insured Soc. Sec: Employer:

Insured Birth Date: Ins. Company:

Address:

Address:

Address 2:

Address 2:

City,State,Zip: Rem. Benefits:

.00 Rem. Deduct:

City,State,Zip: .00

Spouse Child

Other

Spouse Child

Other

LV SUBURBAN DENTAL ASSOCIATES AMERICAN DENTAL GROUP PC, AMERICAN DENTAL SPECIALTIES PC

DENTAL OFFICE INFORMED CONSENT

It is very important to us that you, our patient, understand that the dental treatments and procedures are not to be taken for granted as being routine or without risk of complications. As with all medical treatment to one's body, including dental treatment, there are no guarantees that the results will be as planned and to each individual's satisfaction. When dealing with the human body, there are potentially many variables, some predictable and others not. Complications rates in dentistry are low but they do exist. Even minor procedure such as "filling" can lead to major complication that can't be foreseen. For example, a "Novocain" injection could lead to allergic reaction, anaphylaxis, facial hemorrhage, swelling, bruising, and even hospitalization or death. Granted these are fairly uncommon occurrences but individuals who are contemplating this should be aware of this prior to consenting. These complications can be transient or may persist requiring further treatments. The above examples are only samples of possible complications with dental treatment and are not limited to these. In general, complications include but are not limited to pain, swelling, bleeding, infection, fractures and other nerve problems. I have read, understand and consent to dental treatments.

TELEPHONE CONSUMER PROTECTION ACT (TCPA): You agree, in order for us to service your account or to collect monies you may owe, American Dental Group PC or American Dental Specialties PC, and/or our agents may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or emails, using any email address you provide to use. Methods of contact may include using prerecorded/ artificial voice messages and/or use of automatic dialing device, as applicable. I/We have read this disclosure and agree that American Dental Group PC or American Dental Specialties PC, its employees and/or agents may contact me/us as described above.

FINANCIAL POLICY 1. PATIENTS WITH INSURANCE COVERAGE:

Please understand that your insurance policy is a contract between you and your insurance company. We are not a party to that contract. We will be glad to help you obtain the appropriate benefits from your insurance carrier as a courtesy to you, but ultimately it is patient's responsibility to understand their insurance benefits. Routine treatments are generally performed without submitting a request of pre-estimate of benefits. Regarding insurance plans where we are a participating provider, all co-pays and deductibles are due prior to the treatment. If your insurance company denies the claim, the balance will be automatically transferred to you. In some cases, insurance carrier may pay for alternative benefits than the treatment performed. In this case you are responsible to pay for the difference. All procedure involving lab work will require 50% down payment, then the remaining 50% balance will be due at the day of final insertion. 2. PATIENTS WITHOUT INSURANCE COVERAGE: Patients without insurance coverage are required to pay for services as rendered. We accept Cash, Check, MasterCard, Visa, Discover, American Express or Debit/ATM cards. We also offer patient financing plans. 3. ALL PATIENTS: a. Unless other arrangements have been made in advance, all copay and deductibles must be paid at the time of service. You may

have to pay approximate payment towards the co-payment for the dental treatments. We may keep the credit balance, if any, towards your future treatment. It is your responsibility to request our office for a statement of accounts or a refund of your credit balance. b. Checks returned unpaid from the bank, or credit card chargebacks are subject to $30.00 service fee. d. Accounts delinquent more than 60 days from the date of billing are subject to a 1.5% per month (18% annually) finance charge. If your account is sent to our collection agency, you will be responsible for collection and court costs along with attorney's fees.

Office Policy Concerning Scheduling Appointments

When you make an appointment, we reserve that time for you. We understand that extreme or unavoidable emergencies or circumstances do arise which may require you to cancel your appointment. We reserve the right to charge for any appointment(s) broken without 24 hours advance notice. The charge will be $50.00 for every thirty minutes of appointment time reserved.

We welcome you to our office and want to provide you service with the best possible care. If you have any questions regarding our policies and your treatment, please do not hesitate to ask. I HAVE READ AND UNDERSTAND THE ABOVE DENTAL OFFICE INFORMED CONSENT, FINANCIAL POLICIES AND OFFICE POLICY CONCERNING SCHEDULING APPOINTEMTS. I HAVE RECEIVED A COPY OF OFFICE'S NOTICE OF PRIVACY PRACTICES.

X_____________________________________________________________ Signature of Patient/Parent/Guardian

_____________________

Date

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:

Individual refused to sign.

Communications barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

Other (Please Specify)

Medical Alert:

Condition:

Premedication:

Allergies:

Anesthesia:

Date:

HEALTH HISTORY FORM

Name:

LAST

Address:

P.O. BOX or Mailing Address

Occupation:

FIRST

MIDDLE

Home Phone: ( City:

Height:

) Weight:

SS#:

Emergency Contact:

Relationship:

If you are completing this form for another person, what is your relationship to that person?

NAME

Business Phone: ( )

State:

Zip Code:

Date of Birth:

Sex: M u F u

Phone: ( )

RELATIONSHIP

For the following questions, please (X) whichever applies, your answers are for our records only and will be kept confidential in accordance with applicable laws. Please note that during your initial visit you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Do your gums bleed when you brush? Have you ever had orthodontic (braces) treatment? Are your teeth sensitive to cold, hot, sweets or pressure? Do you have earaches or neck pains? Have you had any periodontal (gum) treatments? Do you wear removable dental appliances? Have you had a serious/difficult problem associated with any previous dental treatment? If yes, explain:

DENTAL INFORMATION

Don't Yes No Know u u u u u u u u u u u u u u u u u u

How would you describe your current dental problem?

Date of your last dental exam: Date of last dental x-rays: What was done at that time?

u u u

How do you feel about the appearance of your teeth?

If you answer yes to any of the 3 items below, please stop and return this form to the receptionist.

Have you had any of the following diseases or problems?

Active Tuberculosis Persistent cough greater than a 3 week duration Cough that produces blood

MEDICAL INFORMATION

Don't Yes No Know

Are you taking or have you recently taken any medicine(s) including non-prescription medicine? If yes, what medicine(s) are you taking?

u u u u u u u u u

Prescribed: Over the counter:

Don't Yes No Know

u u u

Are you in good health? Has there been any change in your general health within the past year?

Are you now under the care of a physician? If yes, what is/are the condition(s) being treated?

Date of last physical examination:

Physician:

NAME

ADDRESS

PHONE CITY/ STATE

NAME ADDRESS

PHONE CITY/ STATE

Have you had any serious illness, operation, or been hospitalized in the past 5 years? If yes, what was the illness or problem?

u u u

u u u u u u

Vitamins, natural or herbal preparations and/or diet supplements:

Are you taking, or have you taken, any diet drugs such Pondimin (fenfluramine), Redux (dexphenfluramine) or phen-fen (fenfluramine-phentermine combination)?

u u u

Do you drink alcoholic beverages? If yes, how much alcohol did you drink in the last 24 hours? In the past week?

u u u

ZIP ZIP

u u u

Are you alcohol and/or drug dependent?

u u u

If yes, have you received treatment? (circle one) Yes / No

Do you use drugs or other substances for recreational purposes? If yes, please list:

Frequency of use (daily, weekly, etc.):

Number of years of recreational drug use:

u u u

Do you use tobacco (smoking, snuff, chew)? If yes, how interested are you in stopping? (circle one) Very / Somewhat / Not interested

Do you wear contact lenses?

PLEASE COMPLETE BOTH SIDES

u u u u u u

Are you allergic to or have you had a reaction to? Local anesthetics Aspirin Penicillin or other antibiotics Barbiturates, sedatives, or sleeping pills Sulfa drugs Codeine or other narcotics Latex Iodine Hay fever/seasonal Animals Food (specify) _________________________________________ Other (specify) _________________________________________ Metals (specify) ________________________________________

Don't Yes No Know

u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u

To yes responses, specify type of reaction.

Don't Yes No Know

Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement? If yes, when was this operation done?

u u u

If you answered yes to the above question, have you had any complications or difficulties with your prosthetic joint?

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? If yes, what antibiotic and dose? Name of physician or dentist*: Phone:

WOMEN ONLY Are you or could you be pregnant? Nursing? Taking birth control pills or hormonal replacement?

u u u

u u u u u u u u u

Please (X) a response to indicate if you have or have not had any of the following diseases or problems.

Abnormal bleeding

AIDS or HIV infection

Anemia

Arthritis

Rheumatoid arthritis

Asthma

Blood transfusion. If yes, date: _________________________

Cancer/Chemotherapy/Radiation Treatment

Cardiovascular disease. If yes, specify below:

____ Angina

____Heart murmur

Don't Yes No Know u u u u u u u u u u u u u u u u u u u u u u u u u u u

Don't Yes No Know

Hemophilia

u u u

Hepatitis, jaundice or liver disease

u u u

Recurrent Infections

u u u

If yes, indicate type of infection: ________________________

Kidney problems

u u u

Mental health disorders. If yes, specify: __________________ u u u

Malnutrition

u u u

Night sweats

u u u

Neurological disorders. If yes, specify: ___________________ u u u

Osteoporosis

u u u

____ Arteriosclerosis ____ Artificial heart valves

____High blood pressure ____Low blood pressure

Persistent swollen glands in neck Respiratory problems. If yes, specify below:

u u u

____ Congenital heart defects ____Mitral valve prolapse

____ Emphysema

____ Bronchitis, etc.

____ Congestive heart failure ____ Coronary artery disease ____ Damaged heart valves ____ Heart attack

____Pacemaker ____Rheumatic heart

disease/Rheumatic fever

Chest pain upon exertion Chronic pain Disease, drug, or radiation-induced immunosurpression Diabetes. If yes, specify below: ____ Type I (Insulin dependent) ____Type II

u u u u u u u u u u u u

Dry Mouth

u u u

Eating disorder. If yes, specify: ________________________________________________ u u u

Epilepsy

u u u

Fainting spells or seizures

u u u

Gastrointestinal disease

u u u

G.E. Reflux/persistent heartburn

u u u

Glaucoma

u u u

Severe headaches/migraines Severe or rapid weight loss Sexually transmitted disease Sinus trouble Sleep disorder Sores or ulcers in the mouth Stroke Systemic lupus erythematosus Tuberculosis Thyroid problems Ulcers Excessive urination

Do you have any disease, condition, or problem not listed above that you think I should know about? Please explain:

u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u

u u u

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

SIGNATURE OF PATIENT/LEGAL GUARDIAN

DATE

FOR COMPLETION BY DENTIST Comments on patient interview concerning health history:

Significant findings from questionnaire or oral interview:

Dental management considerations:

Health History Update: On a regular basis the patient should be questioned about any medical history changes, date and comments notated, along with signature.

Date

Comments

Signature of patient and dentist

____________________________ __________________________________________________________________________________________ _________________________________________________________________________

____________________________ __________________________________________________________________________________________ _________________________________________________________________________

?2002 American Dental Association

S500

AMERICAN DENTAL GROUP PC

AMERICAN DENTAL SPECIALTIES P.C.

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 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 04/14/2003, 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 a ny time, provided such changes are permitted by applicable law. We reserve the ri ght to make the c hanges in our privacy practices and th e new terms of our N otice 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 o r disclose your health i nformation to a ph ysician 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 d isclose your health information in co nnection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of he althcare 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 tre atment, payment or healthcare operations, you may give us written authorization to us e your health information or to d isclose it to an yone for a ny 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. W e may disclose your health information to a fa mily 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 n otify, or assist in the notification of (including identifying or locating) a fam ily 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 d etermination 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 e xperience with common pr actice to make reasonable inferences of your best interest in all owing a person to pick u p filled prescriptions, medical supplies, xrays, 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 abus e, neglect, or dom estic violence or th e possible victim of other crimes. W e 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. W e may disclose to authorize d federal officials health information required for la wful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of pr otected health information of inmate or p atient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as 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, we will charge you $25 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 or our business associates disclosed your health information for purposes, other tha n treatment, p ayment, healthcare operations and c ertain 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 req uest that we place additional restrictions on our use or disc losure of your health information. We are n ot 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 ri ght 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 specif y the a lternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have th e right to requ est that we amend your health information. (Your requ est must be in writing, and it must explain why the information should be amended.) W e 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 your privacy rights, or you 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 your health information or to have us communicate with you 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 health 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.

Telephone: (610) 820-9900

Fax: (610) 820-9922

E-mail: lvsuburbandental@

Address: 1651 Cedar Crest Blvd. Ste#206, Allentown, PA 18104

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