ProSites, Inc.
WELCOMEPatient InformationToday's Date:______/______/______ E-Mail:_____________________________________Name: ____________________________________________ Nickname: ________________________ (Last) (First) (M)Birthdate: ______/______/______ Soc. Sec. #: _____________________ Sex: (circle one) MALE FEMALEMailing Address: _____________________________________ City: ______________ State: ________ Zip: __________Home #: (______)_________________ Cell #: (______)_________________ Work #: (______)__________________Marital Status: (circle one) SINGLE MARRIED DIVORCED WIDOWED How did you hear about our office? ______________________________Other family members seen by us: _____________________________________________________________________Emergency Contact: ___________________________ Phone #: (______)_____________________Pharmacy Name:__________________________ Location:__________________________ Phone #:___________________Insurance InformationPrimary Insurance Carrier: _____________________ Subscriber ID#: __________________ Group #: _____________Insurance Mailing Address: ____________________________ City: ________________ State: ________ Zip: __________Employer Name: _______________________________________Name of Insured: ___________________________ Birthdate: ______/______/______ Soc. Sec. #: _______________Secondary Insurance Carrier: _____________________ Subscriber ID#: _________________ Group #: ____________Insurance Mailing Address: ____________________________ City: ________________ State: ________ Zip: __________Employer Name: _______________________________________Name of Insured: ___________________________ Birthdate: ______/______/______ Soc. Sec. #: __________________Dental HistoryAre you currently experiencing any discomfort? YES NO If yes, please describe: _________________________________________________Are you required to take antibiotics before an dental treatment? YES NODo your gums ever bleed? YES NOHave you ever been told you have Periodontal Disease? YES NOYour current dental health is: (circle one) GOOD FAIR POORDo you Floss daily? YES NODo you Brush daily? YES NOWhat type of bristles do you use? (circle one) HARD MEDIUM SOFT Are your teeth sensitive to heat, cold or anything else? YES NOLast Dental Visit? __________________________Are you happy with the way your smile looks? YES NO If not, what would you change? ______________________________________________________________________________________________________________________________________________Medical HistoryPrimary Care Physician: _____________________________ Phone #: (______)_____________________Date of last visit: ___________________ Your current physical health is? GOOD FAIR POORAre you taking any prescriptions or over the counter medication? YES NO If so, please list: _______________________________________________________________________________Preferred pharmacy -Name and location: _______________________________________________________________Do you smoke or use tobacco in any form? YES NO If yes, please describe: __________________________________________________________________________Have you ever been told you snore or hold your breath while you sleep? YES NOHave you ever taken Fosamax or any other Bisphosphonates? YES NOAllergic to any of the following? Aspirin Barbiturates Codeine Dental Anesthetics Erythromycin Jewelry/Metals Latex Penicillin Sedatives Sulfa Drugs Tetracycline Other: ________________Are you taking any of the following? Acetaminophen Blood Thinners Insulin/Diabetes Drugs Steroids/Cortisone Antibiotics Blood Pressure Medication Nitroglycerin Thyroid Medication Antihistamines Cold Medication Recreational Drugs Tranquilizers ________________________________________________________________________________________________For Women Only:Are you taking birth control pills? YES NOAre your Pregnant? YES NO UNSURE If Yes: Week #: __________ Are you Nursing? YES NO_________________________________________________________________________________________________Have you had any of the following diseases or medical problems? (circle all that apply)Acid Reflux Chemo/Radiation Heart Surgery/Pacemaker Liver Disease StrokeAlcohol Abuse Colitis Heart Attack Date: _________ Lupus Thyroid ProblemsAnemia Congenital Heart Defect Heart Murmur Lyme Disease TonsillitisAngina Diabetes Hemophilia/Abnormal Bleeding Mitral Valve Prolapse Tuberculosis Artificial Bones/Joints Drug Abuse Hepatitis Type: ________ Psychiatric Treatment UlcersArtificial Valves Emphysema Herpes/Cold Sores Rheumatic Fever Venereal DiseaseAsthma Epilepsy/Seizures High/Low Blood Pressure Scarlet FeverBlood Transfusion Glaucoma HIV+/AIDS ShinglesCancer Headaches Kidney Problems Sinus ProblemsPatient/Guardian (Print Name) ____________________________________________ Date: _______/_______/________Patient/Guardian Signature: ____________________________________________ Appointment Confirmation /Appointment Cancelation/No Show PolicyThank you for trusting your dental care to Gentle Dental. When you schedule an appointment withour office we set aside enough time to provide you with the highest quality of care. Should you need tocancel or reschedule an appointment please contact our office as soon as possible, and no later than 24 hours prior to your scheduled appointment. This gives us time to schedule other patients who may be waiting for an appointmentAs a courtesy, we send out texts, automated calls, and e-mails to remind you of your upcoming appointment. When time allows, we make reminder calls for the appointments that have not been confirmed prior to your scheduled visit. If you do not receive a reminder call or message, the above Policy will remain in effect.Appointment confirmation is required to keep your scheduled appointment. If we do not receive a verbal or electronic confirmation 24 hrs. in advance your appointment may be canceled. Any patient who fails to show or cancels/reschedules an appointment and has not contacted our office with at least 24 hours’ notice will be considered a No Show and will have ONE chance to reschedule.1st missed appointment: A letter will be sent home reminding you of our policy. You may contact the office to reschedule your missed appointment.2nd missed appointment: After your second missed appointment, another letter will be sent to you notifying you that we will no longer be able to schedule any appointments in advance. You will then be placed on our “Short-notice” list and will be notified of last minute scheduling opportunities. We understand there may be times when an unforeseen emergency occurs, and you may not be able to keep your scheduled appointment. If this is the case, please provide us with a doctor’s note or other adequate proof and we will waive the no show status from your record. You may contact Gentle Dental Locations: Saco: 207-284-6809, Biddeford: 207-283-3775, South Portland: 207-408-0479 Topsham: 207-729-3515. Should it be after regular business hours Monday through Thursday, or a weekend, you may leave a message. I have read and understand the Dental Appointment Cancellation/No Show Policy and agree to its terms.________________________________ _____________________________________Printed NameDate________________________________ _____________________________________Signature (Patient or Parent/Guardian) Relationship to Patient (Self or Parent/Guardian)Financial Agreement Welcome to our Office! We believe in optimum communication with our patients; therefore, we ask that you please read the following information and ask any and all questions so we may help you fully understand our financial and appointment policies. FOR PATIENTS WITH INSURANCE: We are happy to work with your carrier to maximize your benefits and directly bill them for reimbursement for your treatment, but the balance is ultimately the patients’ responsibility. Information that they (your insurance) provide to us is very limited and is not a guarantee that they will cover any procedure. We will provide you with an ESTIMATE of your co-pay, deductible and non-covered services. Please let us know if at any point you are unsure of your financial obligation. Upon request, the office will submit proposed treatment to the insurance carrier for review and pre-estimate. (Most insurance companies need 4-6 weeks to process.) As a courtesy to our patients we do phone your insurance carrier for a breakdown of benefits. Unfortunately, your insurance carrier will not guarantee any information given to us; therefore, we cannot guarantee what percentage of your treatment they will cover. We will provide the service of filling insurance claims on behalf of our patients. The patient is responsible for timely payment of all dental fees regardless of coverage or yearly limitation. If your insurance has not paid or has made a less payment on your behalf, you are responsible for your account and the remaining balance is due and payable by you, the patient. If your insurance has not paid within 90 days, the balance becomes the patient’s responsibility. Any insurance benefits paid subsequently will be refunded to the patient or, if desired, held on the account to be applied to future treatment. FIANCIAL AGREEMENT: Upon acceptance of treatment is this office the patient/guardian assumes financial responsibility for payment of fees. Treatment is to be paid in full when services are rendered unless other arrangements have been discussed and finalized. This may be in the form of cash, check, credit card or other outside financing. If a payment by check is dishonored, the account will be assessed a service fee of $35. Any balance over 90 days old will be assessed a finance charge of 18% APR. In the event it should become necessary to place your account in the hands of an attorney or collection agency, you will be responsible to pay all costs of collection including attorney fees. MINOR PATIENTS: The adult accompanying a minor and the parents/guardians are responsible for full payment, regardless of court child support order. For unaccompanied minors, non-emergency treatment will not be performed until financial arrangements have been made. REGARDING APPOINTMENTS: The doctor reserves appointment times exclusively with each patient. We are committed to being here to serve you and ask that you honor your commitment to us as well. The office reserves the right to charge a missed appointment fee of $50 dollars for repeated short notice cancellations (less than 48 hours) or for those who do not show or their appointments. Please keep us informed of any changes to your health information as well as your address, phone, email or insurance information so that we may serve you in the best possible manner. I have read and understand the above financial policies. I authorize release of any information pertaining to treatment for the purpose of comprehensive filing of insurance claims. For this purpose, a photocopy of this signature is as valid as an original. I authorize payment of primary insurance benefits directly to the dentist otherwise payable to me._____________________________________________________________ ______/______/______ PATIENT/GUARDIAN SIGNATURE _____________________________________________________________ PATIENT NAME Gentle Dental ACKNOWLEDGEMENT OF RECIEPT OF NOTICE OF PRIVACY PRACTICES *You May Refuse to Sign This Acknowledgement* I, ______________________________________________, have received a copy of this office’s Notice of Privacy Practices. ______________________________________________________ Please Print Name ________________________________________________________ ____/____/_____ Signature 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 barrier prohibited obtaining the acknowledgement □ An emergency situation prevented us from obtaining acknowledgement □ Other (Please Specify) ______________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________ Gentle DentalNOTICE OF PRIVACY PRACTICESTHIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOUCAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.OUR LEGAL DUTYWe 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 the Notice while it is in effect. This Notice takes effect November 14, 2009 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 requests.You may request a copy of our Notices 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 INFORMATIONWe 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, or 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 judgement disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgement 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 official’s 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 voicemail messages, text messages, emails, postcards, and letters).PATIENT RIGHTSAccess: 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 contract 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 $0.05 for each page, $25.00 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 or our business associates disclosed your health information for purposes, other than treatment. payment, healthcare operations and contain 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 alterative locations. (You must make your request in writing.) Your request must specify the alterative 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 website or by electronic mail (e-mail), you are entitled to receive this Notice in written form.QUESTIONS AND COMPLAINTSIf 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 alterative 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.Contact Officer. Stefanie Hopkins Telephone: 207-560-9061 E-mail: Stefanie@ Address: Gentle Dental. 1290 Congress St. Portland ME 04102 2002 American Dental AssociationAll Rights Reserved Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.This form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002) ................
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