Sansone Family Dental Practice LLP

INSURANCE COVERAGE
Primary:
Dental Coverage

YesNo
Insurance Co Name
Insurance Co Address
Insurance Co Phone Number
Please enter a valid phone number.
Group # (Plan, Local or Policy #)
Insured's Name
Relation
Insured's Birthdate

MonthDayYear
Date
Insured's ID #
Insureds Employer
Secondary:
Dental Coverage

YesNo
Insurance Co Name
Insurance Co Address
Insurance Co Phone Number
Please enter a valid phone number.
Group # (Plan, Local or Policy #)
Insured's Name
Relation
Insured's Birthdate

MonthDayYear
Date
Insured's ID #
Insured's Employer

EMERGENCY CONTACT / RESPONSIBLE PARTY INFORMATION
In the event of an emergency, is there someone who lives near you that we should contact?
Name
Relation
Work Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Spouse Information
Name
Employer
Work Phone Number
Please enter a valid phone number.
Ext
SS#
Birthdate

MonthDayYear
Date
Drivers License #
Person Responsible for Account
Name
Work Phone Number
Please enter a valid phone number.
Ext
Home Phone Number
Please enter a valid phone number.
Billing Address
Relation
SS #
Employer
DL #

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

Payment is due in full at the time of treatment unless prior arrangements have been approved.
Signature

Clear
Date

MonthDayYear
Date
If this office accepts 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.
Signature

Clear
Date

MonthDayYear
Date
Our office is HIPAA Compliant and committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

HIPAA AND NOTICE OF PRIVACY PRACTICES
I understand that, under the Health Insurance Portability & Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
- Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
- Obtain payment from third-party payers.
- Conduct normal healthcare operations such as quality assessments and physician certifications.
I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures 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 at the address above to obtain a current copy of the Notice of Private 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 then you are bound to abide by such restrictions.
Patient/Guardian of Patient Name:
Relationship to Patient
Signature

Clear
Date

MonthDayYear
Date

CONSENT FOR DISCLOSURE OF HEALTH INFORMATION
PATIENT NAME
We will use the following methods to contact you in order to conduct business relating to your dental/medical treatment, including, but not limited to, appointments, reminders, medical results, billing and/or insurance questions:

Home Phone, Work Phone, Cell Phone, Text Message, With another person, Via mail, Via email/electronically.
Please indicate below if there are any methods you DO NOT want us to use
Is there a family member, friend, or person responsible for your care that you would like us to be able to communicate with regarding your treatment and/or information from this office? If so, please list below:
Person #1:
Name

First NameLast Name
Relationship
Person #2:
Name

First NameLast Name
Relationship
Person #3:
Name

First NameLast Name
Relationship
Patient Signature

Clear
Parent/Guardian Signature (if Needed)

Clear
Date

MonthDayYear
Date

FINANCIAL POLICY
Thank you for choosing us as your dental care provider. The following is a statement of our Financial Policy which we ask you to read carefully and sign prior to treatment.
REGARDING INSURANCE
Your insurance policy is a contract between you and your insurance company.

It is our policy to charge our patients and their insurers in a fair and consistent manner. Our fees are set at usual and customary rates for this area.

All insurance information including changes and updates need to be provided to us at the time of service.

Payment in full is due at the time services are rendered. We will submit all claims to your insurance company electronically to expedite their direct reimbursement to you. Please note some, and perhaps all, of the services provided may be non-covered under your insurance plan.

If you have more than one dental insurance policy, upon receipt of payment from primary insurance carrier, please send the explanation of benefits to us and we will gladly submit to your secondary insurance carrier for you.
PAYMENTS
We accept cash, checks, American Express, Discover, Mastercard, and Visa. We also accept Care Credit. Should you make a payment by check, and it is returned unpaid, a fee of $50.00 will be charged to your account.
BROKEN APPOINTMENTS
There will be a fee based on visit type for broken appointments or cancellations not made 24 hours in advance of the appointment.
In the event that Sansone Family Dental Practice, L.L.P. pursues civil remedies against me for the collection of my financial obligations for services rendered, I hereby agree to be responsible for reasonable collection and/or attorney fees and disbursements incurred by Sansone Family Dental Practice, L.L.P.

I have read this Financial Policy and understand and agree to be personally and fully responsible for payment.
Patient Name (Legal Guardian if under 18 years of age)
Patient Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

	Yes	No
Abnormal Bleeding
Alcohol / Drug Abuse
Anemia
Arthritis
Artificial Bones / Joints / Valves
Asthma
Blood Transfusion
Cancer / Chemotherapy
Colitis
Congenital Heart Defect
Diabetes
Difficulty Breathing
Emphysema
Epilepsy
Fainting Spells
Frequent Headaches
Glaucoma
Hay Fever
Heart Attack
Heart Murmur
Heart Surgery
Hemophilia
Hepatitis
Herpes / Fever Blisters
High Blood Pressure
HIV+ / AIDS
Hospitalized for Any Reason
Kidney Problems
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Pacemaker
Psychiatric Problems
Radiation Treatment
Rheumatic / Scarlet Fever
Seizures
Shingles
Sickle Cell Disease / Traits
Sinus Problems
Stroke
Thyroid Problems
Tuberculosis (TB)
Ulcers
Venereal Disease

	Yes	No
Aspirin
Codeine
Dental Anesthetics
Erythromycin
Jewelry
Latex
Metals
Penicillin
Tetracycline

WELCOME

ABOUT YOU

INSURANCE COVERAGE

EMERGENCY CONTACT / RESPONSIBLE PARTY INFORMATION

Spouse Information

Person Responsible for Account

MEDICAL HISTORY

For Women:

MEDICAL HISTORY

DENTAL HISTORY

HIPAA AND NOTICE OF PRIVACY PRACTICES

CONSENT FOR DISCLOSURE OF HEALTH INFORMATION

FINANCIAL POLICY

REGARDING INSURANCE

PAYMENTS

BROKEN APPOINTMENTS