Alumni Dental Center Child Patient Form

Alumni Dental Center Child Patient Form

Patient Registration - Under 18
Patient Information
Patient's Name*

First NameMiddle NameLast Name
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*
example@example.com
Check which option you want us to contact you regarding your appointments:*

Call HomeCall WorkCall CellText
Date of Birth*

MonthDayYear
Date
Social Security #
If Patient is a minor, give parents or guardians name:
Whom may we thank for referring you to our office?

Responsible Party Information
Name*

First NameMiddle NameLast Name
Residence

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing 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.
Social Security #
Date of Birth

MonthDayYear
Date
Relationship to Patient*
Employer*
Occupation*
# Years Employed*
Spouse's Name

First NameMiddle NameLast Name
Relationship to Patient
Social Security #
Date of Birth

MonthDayYear
Date
Work Phone
Please enter a valid phone number.
Consent for Minor
Since type child's name here is a minor, it is necessary that a signed permission is obtained from a parent or legal guardian before any dental services can be started and accomplished by Drs. Kopczyk, Vieth, Majors and or their legally qualified associates. Such authorization is hereby granted to administer any treatment, anesthetics, and perform such procedures or otherwise manage my child as may be deemed necessary. I understand I will be consulted before any treatment is done.
Parent's / Guardian's Signature*

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Date*

MonthDayYear
This field is required.

Communication
How would you like us to communicate with you?

Our dental office sends appointment reminders, information about treatment, payment and insurance, and other communications. Please tell us how you would like us to communicate with you.
Your Name*

First NameLast Name
Today's Date*

MonthDayYear
This field is required.
Check or Complete ALL THAT APPLY:

Contact me by U.S. MailContact me by email
Please provide the corresponding U.S. Mail and/or Email address from the previous question:
For Phone and Text Communications:

This form is optional. You are not required to sign this form, and you do not need to sign it to receive care in our dental office.
Phone Number
Please enter a valid phone number.
The dental practice may:

Call meText meCall me and Text me
By checking this box, I consent to the following: The dental practice or its service provider may contact me to provide health care information such as appointment reminders and information about treatment, payment, my account or insurance, using artificial or prerecorded voice or telephone equipment that may be capable of automatic dialing.
Signature Here

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Date

MonthDayYear
Date
PLEASE CALL THE DENTAL OFFICE RIGHT AWAY IF YOU GET A NEW TELEPHONE NUMBER!
For office use only:
1. Consent revoked:Date / Initials
2. Possible reassigned number: Date / Initials
3. Confirmed accurate: Date / Initials

2018 Financial Agreement
At Alumni Dental Center, we are committed to providing you with the highest quality dental care and excellent service. As part of this committment, we strive to provide you with a clear understanding of your financial obligations to our proactice. If you have any questions about the following financial policy, we encourage you to contact our patient accounts department.

PATIENTS WITH INSURANCE COVERAGE:

As a courtesy to you we will file all of your insurance claims. Your estimated copayment, the amount not covered by your insurance, and the deductible are due in full at the time of service. Your copayment may be adjusted after the time of service depending upon the final payment made by your insurance. Ultimately, you are responsible for hte account if insurance payment is not received. We will attempt to collect payment from your insurance company for 90 days. After 90 days any account balance is your responsibility, however, we will gladly assist you in trying to recover payment from your insurance company.

PATIENTS WITHOUT CAPITATION PLANS:

Capitation plans are a reduced fee for service and no insurance claims are filed. Your portion is due in full at the time of service.

PATIENT WITHOUT INSURANCE COVERAGE:

Unless prior arrangements are made with our financial coordinator, payment IN FULL is due at the time of service. As part of our commitment to provide affordable dental care, we will continue to offer discounts for our cash paying patients.

PAYMENTS:

For your convenience, we accept cash, checks, Visa, Mastercard, American Express, Discover, and CareCredit. CareCredit is an outside financing company that offers an affordable way to finance dental work. Please contact our office if you have questions about applying for CareCredit.

THIRD PARTY PAYMENTS:

We understand that sometimes a family member or friend may want to help you with your dental needs. We gladly accept third party payments after certain arrangements have been made. Due to HIPAA privacy laws, we will need your permission to speak to the responsible party about your treatment. We will also need to speak to the third party BEFORE your appointment to make firm payment arrangements. If the third party cannot be reached, you are ultimately responsible for payment IN FULL at the time of service.

RETURNED CHECKS:

Due to the expense of processing checks returned by the bank, we charge a $35.00 service fee.

BROKEN APPOINTMENT:

Appointments that are not kept or that are not cancelled with at least 24-hour notice are subject to a $75.00 fee.

"The undersigned agrees that if this account is not paid when due, and Alumni Dental Center should retain an attorney or collection agency for collection, the undersigned agrees to pay all costs of collection including court costs, reasonable interest, reasonable attorney's fees and reasonable collection agency fees."
Signature*

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Date*

MonthDayYear
Date

ASSIGNMENT OF BENEFITS
Date:

MonthDayYear
Date
Patient:
Insured's Name

First NameLast Name
Insured's Employer
Claim Group
Insured's SS#/ID#
Date of Birth

MonthDayYear
Date
Do you have dual coverage?

YesNo
I hereby instruct and direct name of insurance company to pay by check made out to:
Alumni Dental Center

Dr. Larry Kopczyk DMD

Dr. Brian Vieth DMD

Dr. Tim Majors DMD

OR

If my current policy prohibits direct payment to the doctor, I hereby also instruct and direct you to make out the check to me and mail it as follows:
Alumni Dental Center, 2335 Sterling Road, Ste 200, Lexington, KY 40517
For the professional or medical expense benefits allowable, and otherwise payable to me under my current insurance policy as a payment toward the total charges for the professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY.

A Photocopy of this Assignment shall be considered as effective as the original.

I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in the case.

I authorize doctor to initiate a complaint to the Insurance company for any reason on my behalf.
Signature*

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Date*

MonthDayYear
This field is required.
Witness

NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY, THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duty, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice effective starting 04/01/2003, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and health care operations. For Example:

Treatment: We may use and disclose your health information to a physician or other health care providers providing you treatment.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Health Care Operations: We may use and disclose your health information in connection with our health care operations. Health Care operations include quality assessment and improvement activities, reviewing the competence or qualification of health care professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorizations: In addition to our use of your health information for treatment, payment or health care operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not effect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family & Friends: We must disclose your health information to you to notify, as described in the Patient Rights Section of this Notice. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your health care or with payment for your health care, but only if you agree that we may do so.

Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or location) as a family member, your personal representative or another person responsible for your care, your location, your general condition, or death. If you are present, then prior to use of disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgement disclosing only health information that is directly relevant to the person's involvement in your health care. We will also use our professional judgement and our experience with the common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communication without your written consent.

Required By Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your safety or the health and safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement officials having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail, postcards, letters, text and emails).

Patient Rights

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associated disclosed your health information for purposes other than treatment, payment, health care operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12 month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with your about your health information bu alternative means or to an alternative location. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. Your request must be in writing, and must explain why the information should be amended. We may deny your request under certain circumstances.

If you have any concerns or questions that involve your privacy rights you may contact us by phone at 859-273-5556, by email at info@alumnidental.com, or in writing to our mailing address listed at the beginning of this Notice. You may also submit a written complaint to the U.S. Department of Health and Human Services.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

**You May Refuse to Sign This Acknowledgement**
I, enter your name here have reviewed a copy of this office's Notice of Privacy Practices.
Signature

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Date

MonthDayYear
Date
**FOR OFFICE USE ONLY**
We attempt to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Individual refused to signCommunication barriers prohibited obtaining the acknowledgementAn emergency situation prevented us from obtaining acknowledgmentOther (Please Specify)
Should be Empty:

Alumni Dental Center Child Patient Form

Patient Information

Responsible Party Information

Dental History

Medical History

Communication

For office use only:

2018 Financial Agreement

ASSIGNMENT OF BENEFITS

NOTICE OF PRIVACY PRACTICES

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES