Thank you for visiting PARK DENTAL CARE. We want your visit to be pleasant and comfortable.Please help us by completing this form
Personal Details
Title:
First Name:
Last Name:
Middle Initial:
Preferred Name:
Date Of Birth:
Social Security Number:
Gender:
Marital Status:
Referred By:
Responsible Party (if someone other than the patient)
First Name:
Last Name:
Middle Initial:
Street Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Work Phone:
Ext:
Date Of Birth:
Social Security Number:
Driver's License:
Patient Information
Please select below
Responsible Party is also a Policy Holder for Patient?
Yes
No
Primary Insurance Information
Insurance Co. Name:
Insurance Co.Address:
City:
State:
Zip Code:
Insured Name:
Insured Social Security:
Insured Birth Date:
Relationship:
Insured Employer:
Employer's Address:
City:
State:
Zip Code:
Rem. Benefits:
Rem. Deduct:
Secondary Insurance Information
Insurance Co. Name:
Insurance Co. Address:
City:
State:
Zip Code:
Insured Name:
Insured Social Security:
Insured Birth Date:
Relationship to Insured:
Insured Employer:
Employer's Address:
City:
State:
Zip Code:
Rem. Benefits:
Rem. Deduct:
Are you allergic to any of the following?
Do you or Have you experienced the following ?
Financial Responsibility
All professional services rendered are charged to the patient and are due at the time of service, unless other arrangements have been made in advance with other business office. Necessary forms are will be completed to file for insurance career payments.
Assignment of Benefits: I hereby assign all surgical benefits, to include major medical benefits to which I am entitled. I hereby authorise and direct my insurance carrier(s), including Medicare, private insurance and any other health / medical plan, to issue payment check(s) directly to (Practice name)
Medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understood that I am responsible for any amount not covered by insurance or the agreed amount for services rendered.
Authorization to Release information I hereby authorize
(Practice Name)
To: (1) release any Information necessary to insurance carriers regarding my illness and treatments
(2) Process Insurance claims generated, In the course of examination or treatment and
(3) Allow a photocopy of my signature to be used to process insurance claims for the period of life time.
This order will remain In effect until revoked by me in writing. I have requested medical services from:
(Practice Name)
On behalf of myself and/or my dependents, and understand that by making this request. I become fully financially responsible for any and all charges incurred In the course of the treatment authorized.
I hereby affirm that any payment made to me by my insurance carrier will be immediately transferred to.
(Practice Name)
Upon receipt for services rendered
I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges Incurred In full Immediately upon presentation of the appropriate statement EOB or Check.
A photocopy of this assignment is to be considered as valid as original.
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FINANCIAL POLICY
Please read carefully and sign to acknowledge understanding and agreement.
Thank you for choosing us as you dental care provider. We are committed to providing you with the best dental care available.
Available Payment Options:
You can choose from - Cash, Check, Visa, Mastercard, American Express We offer a 5% courtesy adjustment to patients who pay for their treatment, of $ 1000 or more, at the time of scheduling your next appointment. CareCredit payment plan option, ask us for detailed information.
Regarding Insurance:
- For covered services, we ask that all co-pays and deductibles be paid on the day of treatment. Since your insurance company may not cover all costs, we ask that you pay any percentage of your balance not paid by your insurance on the day of treatment.
- For services that are not covered by your insurance, we ask that you pay the entire fee the day of your treatment.
- We will attempt to answer any questions we can about your insurance and, when possible we will assist in resolving complications with your insurance company. Please understand that we cannot speak on their behalf. Your insurance contract is an agreement between you, your employer and your insurance carrier. In the event that your insurance company has not paid (on your behalf), you will be responsible to pay your account.
Patients without Insurance:
- For those patients without insurance coverage, you will be responsible for payment on the day of treatment. If you are not able to pay in full, or if your treatment requires several visits, you will be given an estimate and will be able to discuss payment arrangements with a member of our business office staff.
Cancellation/No Show Policy:
- Our office requires 48 hours’ notice to cancel your appointment in the case of an emergency. We reserve the right to charge a fee, of $50, for those not giving 48 hours’ notice.
Collections
- A charge of $25 will be added to your account for any returned checks. You are responsible to pay all costs of collecting, or attempting to collect any debt owed on this account. This includes all attorney's fees, interest and late fees.
X-Rays:
- You are responsible to pay a $20 fee for duplicate copies of your x-rays
I hereby authorize payment to Park Dental Care by the group insurance, otherwise payable to me.
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General Consent
- During the course of treatment, I may undergo procedures in all phase of dentistry including periodontics (gum treatment and surgery ), oral surgery, endodontics (root canals), fixed and removable prosthodontics (crowns, bridges and dentures) , implant dentistry , restorative dentistry, temporomandibular disorder treatment, sleep apnea treatment, oral pathology, pediatric dentistry, and radiography. Some of the procedures may be performed by a dental profession other than the dentist including a dental assistant or dental hygienist that have been trained to perform certain tasks and is allowable by Florida law.
- I will provide a through and complete medical history, supply a full list of my medications with dosages, and consent to my dentist communicating with my other medical practitioners to inquire about any aspect of my health history.
- No guarantees can be made about treatment outcomes, restoration longevity or prognoses. I understand that any branch of medicine, including dentistry can involve unanticipated results.
- Payment is due the day of service and I am responsible for the full amount owed regardless of any insurance policy I may or may not have. The practice will help in filling any forms needed for insurance reimbursement and those payments will be given to the patient. There is no guarantee that an insurance company will cover work that may be performed.
- My treatment plan may change at any time and I will do my best to approach my dental care with optimism and open communication with my dentist, hygienist and dental office staff.
- I am welcoming to ask questions about any aspects of my dental care and will request information if I am confused or need more information. I am responsible for clarifying any aspects of my treatment that I am unsure about.
Most dental procedures require the use of dental anesthetic or numbing to complete the procedure. I understand that there are risks involved in using anesthetic which include permanent or temporary loss of feeling and or muscle control from nerve damage, pain from injection site including muscle tightness or even muscle damage that may or may not go back to normal, allergic reaction, and any other side effects as
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NOTICE OF PRIVACY PRACTICES
Park Dental Care
29-14 Ditmars Blvd
Astoria, NY 111105
Phone:718 – 274 – 1515
Fax 718 – 274 – 5438
Office contact: James Crum
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND Disclosed
We respect our legal obligation to keep health information that identifies you private. We are obligated by law to leave . This notice describes how we product where health information and what rights you have regarding id.
TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS
The most common reason why we use or disclose your health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purpose are: Setting up an appoint for you, examining your teeth, prescribing medicines and faxing them to be filled, referring you to another doctor or clinic for other health care or services or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are asking you about your health or dental care plans, or other sources of payments preparing and sending bills or claims and collecting unpaid amounts(either ourselves or through a collection agency or attorney). “health care operations ” means those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are Financial or billing audits; internal quality assurance; personnel decisions participation in manages care plans; defence of legal matters; business planning ; and outside storage of our records.
We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside of our office for anything not listed here we will ask you for special written permission.
Uses and Disclosures for other reasons without permission
In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up our office at all. Such users or disclosures are
- When a state or federal law mandates that certain health information be reported for a specific purpose;
- For public health purposes, such as contagious disease reporting, investigation or surveillance and notices to and from the federal food and drug administration regarding dugs or medical devices.
- Disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;
- uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws;
- disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
- disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else;
- disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations;
- uses or disclosures for health related research;
- uses and disclosures to prevent a serious threat to health or safety;
- uses or disclosures for specialized government functions, such as for the protection of the President or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;
- disclosures of de-identified information;
- disclosures relating to worker's compensation programs;
- disclosures of a "limited data set" for research, public health, or health care operations;
- incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
- disclosures to "business associates" who perform health care operations for us and who commit to respect the privacy of your health information;
Unless you object, we will also share relevant information about your care with your family or friends who are helping you with your dental care.
APPOINTMENT REMINDERS
We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call or write to notify you of other treatments or services available at our office that might help you. Unless you tell us othenivise, we will mail you an appointment reminder on a post card, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home.
OTHER USES AND DISCLOSURES
We will not make any other uses or disclosures of your health information unless you sign a written "authorization form." The content of an "authorization form" is determined by federal law. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if it's your idea for us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form, or you can use one of ours. If we initiate the process and ask you to sign an authorization form, you do not have to sign it. if you do not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the office contact person named at the beginning of this Notice.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
The law gives you many rights regarding your health information. You can:
- ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to the office contact person at the address, fax or E Mail shown at the beginning of this Notice.
- ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using E mail to your personal E Mail address. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice.
- ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us (or sixty days if the information is stored off-site). You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice.
- ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30 day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to the office contact person at the address, fax or E mail shown at the beginning of this Notice.
- get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want). By law, the list will not include: disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30 day extension of time if we notify you of the extension in writing. If you want a list, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice.
- get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you got one electronically or in paper form already. If you want additional paper copies, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice.
OUR NOTICE OF PRIVACY PRACTICES
By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office, have copies available in our office, and post it on our Web site.
COMPLAINTS
If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the US. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax or E mail shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.
FOR MORE INFORMATION
If you want more information about our privacy practices, call or visit the office contact person at the address or phone number shown at the beginning of this Notice.
ACKNOWLEDGEMENT OF RECEIPT
I acknowledge that I received a copy of Park Dental Care's Notice of Privacy Practices.
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AUTHORIZATION FOR RELEASE OF IDENTIFYING HEALTH INFORMATION
Patient name
Patient address
Patient phone number
I authorize the professional office of my dentist named above to release health information identifying me [including if applicable, information about HIV infection or AIDS, information about substance abuse treatment, and information about mental health services] under the following terms and conditions:
1. Detailed description of the information to be released:
2. To whom may the information be released [name(s) or class(es) of recipients]:
3. The purpose(s) for the release (if the authorization is initiated by the individual, it is permissible to state "at the request of the individual" as the purpose, if desired by the individual):
4. Expiration date or event relating to the individual or purpose for the release:
It is completely your decision whether or not to sign this authorization form. We cannot
refuse to treat you if you choose not to sign this authorization.
If you sign this authorization, you can revoke it later. The only exception to your right to revoke is if we have already acted in reliance upon the authorization. If you want to revoke your authorization, send us a written or electronic note telling us that your authorization is revoked. Send this note to the office contact person listed at the top of this form.
When your health information is disclosed as provided in this authorization, the recipient often has no legal duty to protect its confidentiality. In many cases, the recipient may re-disclose the information as he/she wishes. Sometimes, state or federal law changes this possibility.
I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. I AUTHORIZE THE DISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBED IN THIS FORM.
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We now have the ability to email and/or text you, reminding you of your appointments. If
you would like to receive this feature in the future, please read the consent below and
sign.
Consent to Email and/or Text Message for Appointment Reminders
and Other Healthcare Communications:
Patients in our practice may be contacted via email and/or text
messaging to remind you of an appointment, to obtain feedback on
your experience with our healthcare team, and to provide general
health reminders/information.
I consent to receiving appointment reminders and other healthcare
communications/information at that email and/or text from Bullhook Community Health
Center, Inc.
I consent to receive text messages from the practice at my cell
phone and any number forwarded or transferred to that number.
The cell phone number that I authorize to receive text messages for appointment
reminders, feedback, and general health reminders/information is
()Carrier:
I consent to emails, to receive communications as stated
above.
The email that I authorize to receive email messages for appointment reminders and general
health reminders/feedback/information
is.
I understand that this request to receive emails and/or text messages will apply to all
future appointment reminders/feedback/health information unless I request a change in
writing.
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