COVID-19 Patient Screening Form

If there is any new insurance, please e-mail us at: isaacsfamilydental@gmail.com 

We prefer this is done before your dental appointment so we are able to check benefits.

Again, we will only need a copy of your card *if it is new*. If there is no card, please e-mail us the name of the insurance, their telephone #, group #, and a member ID. Thank you!

If any patient answers 'yes' to either question on shortness of breath or coughing, or answers yes to any combination of two other symptoms and the patient does not need emergency care, we may consider not scheduling the patient until symptoms resolve or until patient can provide proof they are not infectious for COVID-19. If you have flown within the last 14 days of your appointment, we will ask that you quarantine for 14 days before coming to any appointment. Dr. Isaacs may want to seek additional information from the patient regarding symptoms.

COVID-19 Request for Treatment

Representations and Consent

I hereby acknowledge and understand that there may be an increased risk that COVID-19 may be transmitted in any place of public accommodation, which includes Isaacs Family Dental. This is to inform you our desire to protect our patients, staff, and the community at large. We are taking every precaution necessary to limit the exposure of any virus within our office.

I understand that despite my health care providers best efforts to identify potential carriers of the virus, we cannot guarantee that we are able to identify such individuals and prevent them from potentially bringing the virus to this office. Despite safeguards instituted to minimize infection, I understand that there is a risk that performing this procedure, and the care associated with it, may result in my becoming infected with the COVID-19 virus. Such infection could further result in significant sickness, disability, or death.

As a prerequisite to obtaining the treatment proposed, I am confirming that I have none of the current commonly known symptoms of COVID-19 (fever, cough, shortness of breath, sore throat, loss of taste and/or smell sensation) and that I have not traveled by airplane, cruise ship, or any other form of public transportation. Further, I have been practicing all current CDC guidelines with respect to ‘social distancing’ and have not been in contact with a person who had a positive test for COVID-19 or suspected to be positive. 

I agree to notify the dental practice within 14 days if I become ill with COVID-19 symptoms or test positive for COVID-19. I understand the dental practice has a legal and ethical obligation to inform me if a staff person I had contact with tested positive for COVID-19 within 14 days. I answered all questions honestly. I am signing this to confirm.

I hereby consent to the treatment proposed by my dentist.

HIPAA

Health Insurance Portability and Accountability Act

IMPORTANT: I understand I can obtain a copy of the Acknowledgement of Receipt of Notice of Privacy Practices.

I hereby give permission for Dr. David Isaacs’ Dental office to disclose information regarding any appointment or treatment to:

MUST LIST NAME(s) IN LAST BOX BELOW

EX: If a spouse calls asking a question regarding a bill on your behalf, we cannot share information unless their name is listed OR in order for us to submit your dental claim on your behalf, Insurance Company must be checked.

 o    For office use only:

We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained due to patient refusal. Refusal to sign, we will give copy of the claim to the patient for them to submit their claim to their dental insurance.

OFFICE POLICIES

I hereby guarantee payment in full of any and all fees in consideration for dental services I am responsible for. I understand that I am responsible for all fees not covered by my dental insurance including deductibles and co-payments. I understand payment is due in full for those fees at the time service is performed.

As a courtesy, we contact your dental insurance provider to check your benefits and submit claims on your behalf. We are not responsible for and can make no guarantees as to the coverage your dental insurance will provide. As the patient, it is ultimately your responsibility to know your dental insurance and benefits and you are responsible for any balance that is not paid by dental insurance. We require that all patients, with or without insurance, pay for their treatment at the time of service. We will be happy to file a pre-determination prior to any treatment to your insurance so we can get more of an accurate estimate of what they should pay, but it is still not a guarantee of their payment.

*In an effort to control the cost of our dental fees, we do require a 24 HOUR NOTICE to change or cancel a scheduled appointment. This charge of $25 per hour you were scheduled will automatically be applied to your account.

*We pride ourselves for being on time for your appointment and we ask that you do the same for us. Arriving 15 or more minutes late could result in having to reschedule. More than 3 failed appointments could result in dismissal.

*The office will charge $30 for a returned check. In the event of a returned check, we reserve the right to have you pay in cash for future visits.

*If the account is turned over for advanced collection services, the patient or responsible party will be expected to pay all collection fees ($50 fee), court costs, and reasonable attorney fees.

 In order for you to be seen in our office, you must sign our office policies.