Smpimplants- patient form

Periodontics and Implants Dentistry
99 Navaho Avenue, Suite 102
Mankato, Minnesota 56001
(507)345-7537

PATIENT INFORMATION:

Full Name:*

First NameLast Name

If Child, Name of Guardian:

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth:*

SSN*

Gender*

MF

Email*

example@example.com

Select which applies:*

SingleMarriedChild

Emergency

Contact:*

Relationship:*

Phone Number:*

INSURANCE INFORMATION:

Dental Insurance

Do you have dental insurance?*

YesNo

Please bring a copy of your dental insurance to your next appointment.

Insurance Provider:

Employer

Group #:

Subscriber ID #:

Upload Picture of Insurance Card

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Please fill out below if the subscriber is someone other than yourself

Subscriber’s Name:

Subscriber’s Phone #:

Subscriber’s DOB:

Subscriber’s Social Security Number

Relationship:

Subscriber’s Employer:

Please let us know if you have a secondary insurance.

I understand I am responsible for any balance not covered by Insurance.

Initials/Date*

REFERRAL INFORMATION:

Referred by:

Current Dentist:

How long you have been seen by present dentist:

Do you see your dentist regularly? Circle

YesNo

Have we treated any family or friends?

YesNo

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT – HIPPA

By signing this form, you will consent to our use and disclosure of your protected health of your protected health information (PSI) for the following purposes:

To conduct and plan treatment, including multiple healthcare providers who may be involved in treatment directly or indirectly.
To obtain payment for services provided to you through third-party payers (Insurance Companies)
To conduct normal healthcare operations such as quality assessments, etc.

I have read/been offered a copy of Southern Minnesota Periodontics & Dental Implants, PA’s Notice of Privacy Practices (NOPP) containing a detailed description of the uses and disclosures of PSI that we maintain. I understand that I have the right to revoke this consent at any time by giving written notice of my revocation submitted to your office. Please be aware that we may decline to treat you or to continue treating you if you revoke this consent.

Patient:

Date

Guardian if applicable:

Date

Please sign this form after we present you with our HIPPA

	Prescribed Medications
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SOUTHERN MINNESOTA PERIODONTICS, & DENTAL IMPLANTS, P.A.