New Patient Form

If this office accepts my insurance, I understand, that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the dental office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination required, to my insurance company.

Welcome

The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill this form out completely so that we can provide optimal care for you.

This patient disclosure form seeks information from you that we must consider before making treatment decisions during the COVID-19 virus outbreak

A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID-19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us.

It is also important that you disclose to this office any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.

The following questions apply to anyone entering our office. If you have multiple children, only one form is required for the family.

I am not aware of any risk whereby I might be infected or a possible carrier of COVID-19. I confirm that I have not tested positive for COVID-19 in the last 30 days and that I am not presenting any of the previously stated symptoms of COVID-19

I fully understand and acknowledge the above information, risks, and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history that may result in a compromised immune system.

I understand that JH Dental and Braces is observing the guidelines from the Centers for Disease Control and Prevention for its recommended treatment and infection control protocols, and I willingly and knowingly consent to dental treatment by JH Dental and Braces, including any designated associates and team members during the COVID-19 pandemic.

By signing this document, I acknowledge that the answers I have provided, and the statements above, are true and accurate.

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Patient Acknowledgement of Receipt of Notice of Privacy Practices Pursuant to HIPAA and Consent of Use of Health Information

The undersigned does hereby acknowledge that they have received a copy of this office's Notice of Privacy Practices pursuant to HIPAA and has been advised that a full copy of this office's HIPAA Compliance leaflet is available upon request. The undersigned does hereby consent to the use of their health information in a manner consistent with the Notice of Privacy Practices pursuant to HIPAA, the HIPAA Compliance leaflet, State law and Federal law.

If the undersigned is a parent or guardian of the patient, they do acknowledge and consent to the above paragraph on behalf of the patient.

For more information, contact:
The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
(877) 696-6775 (toll-free)

Our office reserves the right to charge a cancellation fee of $40.00 for all reserved appointments missed or canceled without a 48 hour's notice.

I understand that the office of Dr. Jeffrey W. Henkes will bill my insurance for all appropriate dental treatment as a courtesy. I understand that I am responsible for all estimated co-pays at the the time of treatment. Any fees that are not paid by my insurance company will become my responsibility. Insurance policies and agreements are between the policy holders (patients) and their insurance companies. Any disputes of dental benefits are between these two parties. The dental office will help and support patients with disputed fees with their insurance companies, however, if an insurance balance is not paid within 60 days, the patient will assume responsibility of the balance on their account.