modernendodontics.net - Patient Registration

PATIENT REGISTRATION
PATIENT INFORMATION
* Social Security Numbers are used to verify insurance coverage. If not provided, payment will be expected in full.
Name*

First NameMiddle NameLast Name
Preferred Name:*
DOB: *

MonthDayYear
Date
SS#:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:*
Please enter a valid phone number.
Work Phone:*
Please enter a valid phone number.
Cell Phone: *
Please enter a valid phone number.
Email Address:*
example@example.com
Referred by:*
Are you:*

MarriedSingleDivorcedWidowed
RESPONSIBLE PARTY INFORMATION: (If patient is younger than 18 years old)
Is the patient 18 years or older?

YesNo
Name*

First NameMiddle NameLast Name
Preferred Name: *
DOB:*

MonthDayYear
Date
SS#:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Work Phone:*
Please enter a valid phone number.
Cell Phone:*
Please enter a valid phone number.
Do you or the patient have dental insurance?

YesNo
DENTAL INSURANCE INFORMATION:
As a courtesy to our insured patients, we submit claims to the insurance company free of charge. We will help you to receive your maximum allowable benefits, but we CANNOT guarantee payment from them. In order to do this, we need your insurance information listed below.

If your insurance has not been paid within 60 days of services rendered, you will need to make full payment to this office. You will be reimbursed with your insurance company pays. After 60 days, the patient is responsible to pursue payment from the insurance company. All current documentation will be provided by mail in order to assist your inquiries. The insured, and/or the employer through whom the policy was purchased, has a better ability to deal with the insurance company, as they are the client of the insurance company.
Policy Holder:*
Policy Holder DOB:*
Policy Holder SS#:
Insurance Company:*
Subscriber ID #:*
Group #:*
Employer:*
Claims Address: *
SECONDARY DENTAL INSURANCE INFORMATION:
SECONDARY INSURANCE :

YesNo
* Social Security Numbers are used to verify insurance coverage. If not provided, payment will be expected in full.
Policy Holder: *
Policy Holder DOB:*
Policy Holder SS#:*
Insurance Company:*
Subscriber ID #:*
Group #: *
Employer:*
Claims Address:*
Patient Signature:*

Clear
Date: *

MonthDayYear
Date
Parent/Guardian Signature:(If applicable) *

Clear
Medical History
Patient Name: *
Birth Date: *

MonthDayYear
Date
Date Created:*

MonthDayYear
Date
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Are you under a physician's care now?*

YesNo
Physician's Name:*
Have you been hospitalized or had a major operation in the last 2 years?*

YesNo
Please describe operation:*
Have you ever had a serious head or neck injury?*

YesNo
Please describe head or neck injury:*
Are you taking any medications, pills, or drugs?*

YesNo
Please list medications, pills, or drugs:*
Have you ever taken Fosamax, Boniva, Actonel or any other mediations containing bisphosphonates?*

YesNo
Please list other medications:*
Do you use tobacco?*

YesNo
Women: Are you...

Pregnant/Trying to get pregnant?Nursing?Taking oral contraceptives?
Are you allergic to any of the following?*

AspirinPenicillinCodeineAcrylicMetalLatexSulfa DrugsLocal AnestheticsOther?None of these
If yes*
Do you use controlled substances?*

YesNo
If yes*

Do you have, or have you had, any of the following? *

	Yes	No
AIDS/HIV Positive
Diabetes
Hepatitis B or C
Rheumatic Fever
Rheumatism
Artifidal Heart Valve
Hypoglycemia
Irregular Heartbeat
Spina Bifida
Liver Disease
Glaucoma
Mitral Valve Prolapse
Cold Sores/Fever Blisters
Congenital Heart Disorder
Heart Trouble/Disease
Hemophilia
Hepatitis A
Renal Dialysis
Angina
Arthritis/Gout
Excessive Bleeding
Sickle Cell Disease
Sinus Trouble
Leukemia
Stroke
Lung Disease
Heart Attack/Failure
Heart Murmur
Heart Pacemaker
Psychiatric Care
Radiation Treatment
Anaphylaxis
Anemia
Emphysema
Epilepsy or Seizures
Shingles
Asthma
Blood Disease
Stomach/Intestinal Disease
Low Blood Pressure
Thyroid Disease
Osteoporosis
Pain in Jaw Joints
Parathyroid Disease
Alzheimer's Disease
Drug Addiction
Herpes
High Blood Pressure
High Cholesterol
Artifical Joint
Fainting Spells/Dizziness
kidney Problems
Frequent Headaches
Cancer
Chemotherapy
Tuberculosis
Tumors or Growths
Convulsions

Have you ever had any serious illness not listed above?*

YesNo
If yes*
Dental Questions

What is the reason for today's visit? (Please check all that apply)
Pain*

YesNo
Sensitive to Hot*

YesNo
Sensitive to Cold*

YesNo
Sensitive to Biting or Chewing *

YesNo
Comments*
Electronic Prescriptions

Pharmacy Preference
Do you have a Pharmacy Preference? *
ALL dental report(s) and ALL image(s)*

YesNo
The reason for the release of the Protected Health Information (please check the reason(s) that apply):*

Patient/GP Request (current/continued care)Payment for care, including insuranceLegalOther
(Specify Other) *
I am requesting that the Dental Practice release my Protected Health Information to all relevant corresponding dentists and/or dental specialists involved in the continued care and/or professional observation that request such information. There is NO expiration date on this authorization.

BY MY SIGNATURE, I CERTIFY THAT I HAVE READ AND UNDERSTAND THIS AUTHORIZATION. I AM SIGNING IT VOLUNTARILY. I AUTHORIZE THE DISCLOSURE OF MY PROTECTED HEALTH INFORMATION AS DESCRIBED IN THIS AUTHORIZATION.
Patient/Personal Representative Signature *

Clear
Date*

MonthDayYear
Date
ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES
Read HIPAA Notice of Privacy Practices
*

I acknowledge that I have received a copy of this Dental Practice's HIPAA Notice of PrivacyPractices.
I am the PatientI am a Personal Rep
Patient Name (Please Print)*
Date*

MonthDayYear
Date
Patient Signature*

Clear
Signature of Personal Representative *

Clear
Authority of Personal Representative to Sign for Patient (check one):*

ParentGuardianPower of AttorneyOther
Specify*
Please Note: It is your right to refuse to sign this Acknowledgement.
Financial and Payment Policies
We at Modern Endodontics are prepared to assist you with the various methods of payment available for your endodontic procedure. If you have dental insurance, we will provide an estimate of your co-payment and collect your portion at the time of your appointment. We accept cash, Visa, MasterCard, Discover and American Express. We also offer Care Credit, an outside healthcare financing program that offers interest-free payment plans upon approval. If you do not have dental insurance please understand payment is due at time of service in full.

As a courtesy to our patients, we are happy to submit your claims for services. In order for us to do this, you must provide us with accurate and up-to-date insurance information. We will verify your coverage and plan before your appointment. With this, we will estimate the insurance portion and your co-payment. This may or may not be what the insurance company will actually pay. Your plan may base its dollar allowance on a usual and customary fee schedule which may not coincide with current fees in our area. We'll do our best to help you receive maximum benefits. Patients are responsible for all balances incurred for services received.

If we do not participate with your insurance, we request you pay in full for your treatment. We will submit to the insurance on your behalf. If and once your insurance sends us payment we will be happy to reimburse you.

We will wait 45 days for insurance claims to be paid. After 45 days if payment has not been made, you will be asked to pay the balance and seek reimbursement from your insurance company.

By signing below, you have read and understand the terms and conditions of the financial policy for Modern Endodontics.
Signature of Patient/Responsible Party:*

Clear
Date*

MonthDayYear
Date
Should be Empty:

PATIENT REGISTRATION

SECONDARY DENTAL INSURANCE INFORMATION:

Medical History

Dental Questions

Electronic Prescriptions

ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES

Financial and Payment Policies