Walkdental | Welcome Pack

Merchant Walk Dental, P.C
How did you hear about our office? Or whom may we thank for your referral? (Circle One)
GOOGLE YELP WEBSITE ZOCDOC 1800DENTIST DRIVE BY OTHER PATIENT:
Patient Information:
Patient’s Full Name:*
Nickname:*
SingleMarriedDivorcedSeparatedWidowedMaleFemale
Address:
Apt
City
State
Zip
Social Security Number:
Date of Birth:

MonthDayYear
Employer:
Occupation:
Full Time Student?

YesNo
If Yes, Name/Location of School:
Business Address:
Suite
City
State
Zip
Employee Phone #:
Ext:
Home Phone #:
Cell Phone #:
Email Address:
May we send appointment reminders by email?
Reminders by text message?
Emergency Contact Information:
Full Name:
Relationship to Patient:
Daytime Phone #:
Evening Phone #:
Address:
Apt
City
State
Zip
Primary Insurance:
Insurance Company Name:
Insurance Company Phone #:
Dental Claims Mailing Address:
Social Security #
Member ID #
Group/ Policy #
Employer:
Full Name:
Date of Birth:

MonthDayYear
Secondary Insurance:
Insurance Company Name:
Insurance Company Name:
Dental Claims Mailing Address:
Social Security #
Member ID #
Group/ Policy #
Employer
Full Name:
Date of Birth:

MonthDayYear
I understand that it is my responsibility to immediately notify Merchant walk Dental Dental of any changes to my
address, phone number, work contact information, work status, insurance changes, ect.

Merchants Walk Dental Dental’s Privacy Policy:
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to
privacy regarding my protected health information. I understand that this information can and will be used to:
1. Conduct, plan and direct my treatment and follow- up among the multiple healthcare providers who may be
  involved in that treatment directly and/or indirectly.
2. Obtain payment from third-party payers, such as an insurance company.
3. Conduct normal healthcare operations such as quality assessments and physician certifications.
I have been informed by you or your Notice of Privacy Practice containing a more complete description of the uses and
discloses of my health information. I understand that this organization has the right to change its Notice of Privacy
Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice
of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out
treatment, payment or health care operations. I also understand you are not required to agree to my requested
restrictions, but if you do agree than you are bound to abide by such restrictions.

By signing below, I acknowledge that I have been given the right to review Merchants Walk Dental Dental’s Notice of
Privacy Practices, as mandated by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) prior to
signing this consent.
Signature

Clear
Relationship:
Date

MonthDayYear
Authorization to Discuss Patient Medical Care
How is the information on the form used?
Anytime your designated person(s) calls or makes a request on your behalf, we will verify the individual has your
permission to receive the information and then we will share the information.

What are some examples of when this might be useful?
- If an elderly parent wants an adult child to help understand medical treatment instructions
- If an adult child is helping with billing questions
- If a friend is helping an elderly patient with health issues
- If a college student wants information shared with a parent
- If an adult child calls to find out his/her parent's appointment time
Can the person I designate also get copies of my medical records?
No, they can only receive verbal information. To get copies of medical records, you must complete a separate
Authorization form

What if I change my mind?
You can change or revoke (stop) this process at any time by writing to us at the address shown below.

What happens if I don't complete this form?
We will continue to protect your private health information as required by law.
After a child graduates from high school or turns 18, by law, they must give authorization for their
parents/guardians to receive ANY medical information regardless if they are paying for their treatment.
I,
give permission for the following people to obtain medical information orto speak with Merchants Walk Dental’s staff regarding any of my medical needs.
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Signature

Clear
Date

MonthDayYear
Please verify that you are human*
Should be Empty: