www.martindalefamilydentistry.com - Patient Information Form

Spouse or Responsible Party Information
The following Is for:

The patient's spouseThe person responsible for payment
Name

First NameLast Name
Gender
Marital Status
Social Security #
Birth of Date

MonthDayYear
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Ext
Best time to call?
Address

Street Address

Apartment#

CityState / Province

Postal / Zip Code
Employment Information
Employer Name
Occupation
Address
Phone Number
Please enter a valid phone number.
Insurance Information
Primary
Policy Holder Name

First NameMiddle NameLast Name
Relation to Patient
Policy Holder's Date of Birth

MonthDayYear
ID #
Group #
Policy Holder's Address
Street, City, State, Zip
Insurance Plan Name and Address
Do you have secondary insurance?*

YesNo
Policy Holder Name

First NameMiddle NameLast Name
Relation to Patient
Policy Holder's Date of Birth

MonthDayYear
ID #
Group #
Policy Holder's Address
Street, City, State, Zip
Insurance Plan Name and Address
Consent for Services
As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in full at the time services are performed.

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for the payment of all dental services. This office will help prepare the patient's insurance forms or assist In making collections from insurance companies and will credit any such collections to the patient's account, However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay; therefore, the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if the suit is instituted hereunder.

I grant my permission to you or your assignee to telephone me at home or at my work to discuss matters related to this form.

I have read the above conditions of treatment and payment and agree to their content.
Signature of patient, parent or guardian*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Relationship to Patient

Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment,or Healthcare Operations and Acknowledgement of Health Information Privacy Practices
Patient Name*

First NameLast Name
As part of your healthcare, this practice originates and maintains paper and/or electronic records describing your health history, symptoms, examinations, test results, diagnoses,treatment, and any plans for future care or treatment. This information serves as:
- A basis for planning your care and treatment.
- A means to communicate with health professionals who contribute to your care.
- A source for applying your diagnosis and treatment information for payment purposes.
As part of your treatment, payment, or healthcare operations, it may be necessary to disclose your health information to other healthcare providers(such as referrals to, or consultation with, other healthcare professionals, laboratories, hospitals, etc.), insurance companies for payment, and/or other individuals or agencies as permitted or required by state and federal law. We also may need other healthcare entities to provide us with your healthcare information to be used for planning your care and treatment.
ACKNOWLEDGEMENT
I have been provided the opportunity to receive and/or read the"notice of Privacy Practices" that provides a more complete description of health information uses and disclosures. I understand that I have the following rights:
- The right to read the"Notice of Privacy Practices" prior to signing this consent.
- The right to request a copy of the"Notice of Privacy Practices" for my own personal use.
- The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations
RESTRICTIONS
I request the following restrictions to the use or disclosure of my health information:
(Per HIPAA rules, the practice retains the right for the final decision as to honor the request for restrictions.)
I fully understand and agree to this consent and acknowledge the above rights and disclosures.
Signature*

Clear
Print name of person signing *

First NameLast Name
Date*

MonthDayYear
If other than the patient is signing, are you the parent, legal guardian, custodian, or have Power of Attorney for this patient, for treatment, payment, or healthcare operations.*

YesNo

Our Financial Policy
We are committed to providing you with the best possible care. If you have dental insurance, we are always available to help you receive your maximum allowable benefits.

Payment for services is due at the time services are rendered unless payment arrangements have been approved in advance. We are not responsible for collecting in divorce situations. The guarantee or parent of the account is responsible for the payment of a minor child. Minors MUST be accompanied by an adult for all treatment.

We accept CASH, MAJOR CREDIT CARDS, and CARE CREDIT. Financing is also available upon request, prior to treatment.

Effective March 1, 2021, we will no longer be accepting CHECKS as a form of payment. Please have alternate forms of payment available for services rendered.

In most instances, we accept the assignment of insurance benefits, in which case, your portion of each service is due at the time services are rendered. Those who have dual coverage should discuss their payment plans with the receptionist. If your insurance company pays more than the balance due, we will send a refund check to you immediately.

We will gladly discuss your proposed treatment and answer any questions regarding your insurance. YOU MUST REALIZE, HOWEVER, THAT:
1. Your insurance is a contract between you and your employer and the insurance company.
2. Our fees are generally considered to fall within the acceptable range by most companies, and therefore, are covered up to the maximum allowance determined by each carrier. This applies only to companies who pay a percentage(such as 50% or 80%)or"UCR" is defined
  and Usual, Customary and Reasonable fees for this region; thus, our fees are considered Usual, Customary and Reasonable by most insurance companies. However, this statement does not apply to companies who reimburse based on an arbitrary "schedule" of fees, which bears no relationship to the current standard cost of care in this area.
3. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover.
4. Should your insurance take longer than 60 days to pay, we would ask that you take care of the balance due and then be reimbursed if and when we receive the insurance payment.
Charges may be incurred for broken appointments and appointments cancelled without 24 hours notice.
Effective March 1, 2021, we will no longer be accepting CHECKS as a form of payment. Please have alternate forms of payment available for services rendered.

We must emphasize that as dental care providers, our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the day the services are rendered. We realize that temporary financial problems may affect the timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account.

Your clear understanding of our financial policy is important to our professional relationship. If you have any questions about the above information or any uncertainty regarding insurance coverage, PLEASE don't hesitate to ask us. WE ARE HERE TO HELP YOUl
Responsible party signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear

Website Consent Form
By signing this consent form, you are giving Martindale Family Dentistry permission to use your treatment photographs on our website. Your photographs will be posted on the Martindale Family Dentistry website, as well as social media such as Facebook and Instagram. Your name will not be displayed on the website. If you would like your photographs removed, please contact our office.
I decline the use of my photographsI give Mark Martindale, DDS, PC, permission to use my photographs for the Martindale Family Dentistry website and social media.
Patient signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear

Broken Appointment Policy
We understand that sometimes circumstances arise that prevent patients from maintaining scheduled appointments. It happens to all of us!

If you find it impossible to keep an appointment, please notify our office 24 hours in advance.

Adequate prior notice allows us to reschedule accordingly and see patients promptly.

If we do not receive your cancelation notice 24 hours in advance, you will be charged a $50.00 broken appointment fee that will be assessed prior to your next visit.
Patient signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
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Patient Information Form

Health Information

Have you ever had any of the following? Please check those that apply

Primary Care Physician

Emergency Contact

Referral Information

Spouse or Responsible Party Information

Employment Information

Insurance Information

Primary

Consent for Services

Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment,or Healthcare Operations and Acknowledgement of Health Information Privacy Practices

ACKNOWLEDGEMENT

RESTRICTIONS

Our Financial Policy

Website Consent Form

Broken Appointment Policy