Gulf Coast Dental Outreach Patient Signup

Welcome to Our Office
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Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status*
Occupation*
Employer*
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone Number*

Area CodePhone Number
Who referred you to GCDO?*
Do you have Dental Insurance?*

YesNo
Insurance Company Name*
Insurance Phone Number*
Please enter a valid phone number.

GULF COAST DENTAL OUTREACH, Inc INITAL CONSENT
Patient authorization for First Name* Last Name* , Date*
Consent for Treatment: I First Name* Last Name* hereby authorize Gulf Coast Dental Outreach, Inc. and its agents to perform any tests, x-rays, study models, photographs, treatments or medications that in their professional judgement are considered necessary and advisable for the detection, diagnosis and treatment of oral diseases. I understand that the use of anesthetic agents embodies certain risk.
Authorization for Release of Information: I hereby authorize Gulf Coast Dental Outreach, Inc. clinic to release any past and current health information to (1) other service providers, and the individual(s) designated below, as necessary for the coordination or continuation of my care and (2) third parties as required for quality assurance activities. I further authorize Gulf Coast Dental Outreach, Inc. clinic to receive any such information from other service providers as necessary for the coordination or continuation of my care.
Authorization for payment: I hereby agree to pay all charges connected with this treatment ($25.00 administration fee) for each appointment.
Signature*

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Date*

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Date

Screening Consent Form
Date*

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Sex*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Witness(GCDO staff)___________________________________________
Doctor’s Name__________________________________Address:_________________________
Doctor’s phone:______________________________________
I am being asked to read the following material to ensure that I am informed of the nature of this screening service. Signing this form will indicate that I have been so informed and that I give my consent.
Procedures:

    If I agree to participate in a screening for:

-          Hypertension (high blood pressure), I consent to the measurement of my Blood Pressure using a sphygmomanometer (Blood Pressure Cuff).

-          I consent to the use of Pulse oximeter to be used to check blood oxygen levels and heart rate.

-          I consent to the use of a digital thermometer to measure my body temperature.

Risks:

      If I agree to participate, I am aware that there are NO common serious risks in collecting this

      vital screening information.

Confidentiality:

      By signing this consent form, I allow Gulf Coast Dental Outreach to use my screening and

      patient care data for analysis and reporting. My name, address and phone number will NOT

      be released without my written consent.

Authorization:

      The procedures, risks and confidentiality issues have been explained to me and my

      questions have been answered.
Signature

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Date

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Date

Patient Inactivation Policy
After two (2) missed appointments, a standard letter will be sent to the patient stating the GCDO Inactivation Policy, as a warning letter. A copy of this letter will be placed in the patients chart.

A patient who has arrived more that 15 minutes late for a scheduled appointment (2) two times without notice will receive a standard letter, stating the GCDO Inactivation Policy, as a warning letter. A copy of this letter will be place in the patient’s chart.

A patient will be inactivated for cause, with a letter sent informing the patient of this fact, resulting in permanent inactivation unless that are extenuating circumstances to be determined by the Executive Director or appointed representative of the Board of Directors.
Inactivation is the result of one of the following:

a)      After three (3) missed appointments without 24 hours notice, the patient will be permanently inactivated from GCDO. A letter will be sent, and a copy of the letter will be place in the patient’s chart.

b)      Missed appointments include not texting or calling to confirm your appointment by noon on the Thursday before your scheduled appointment date.

c)      After (3) three late arrivals, the patient will be permanently inactivated from GCDO. A letter will be sent, and a copy will be place in the patients chart.

d)      A patient who has not been in for an appointment for 15 months will be referred to an outside dentist or program at their own cost unless there are extenuating circumstances to be determined by the Executive Director or an appointed representative of the Board of Directors.

e)      Patients with balances owed (the $25 admin fee) for six (6) months or more must pay that balance in full before they will be considered for a next appointment. In addition, the patient’s next visit must also be prepaid prior to the scheduling of that visit.

f)       Patients who do not maintain dental care as prescribed by the dental hygiene staff may be inactivated for non-compliance.

g)      Canceling appointments with a Specialist without 24 hour notice to that Specialist and to GCDO will be cause for inactivation.

h)      Failing to show up for an appointment with a Specialist will be cause for inactivation.

i)        We reserve the right to inactivate those patients who are belligerent, argumentative, verbally abusive and/or willfully misrepresent themselves to our GCDO volunteers, staff or specialists to whom they have been referred.

j)        After the treatment plan has been completed and acceptable dental health has been achieved, patients will be graduated and inactivated from the GCDO program and given resource letters for future treatment, if needed.
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Witness signature_____________________________________Date__________________

Acknowledgement of Receiptand Consent of Notice of Privacy Practices (NPP)
I understand that, under the Health Insurance portability and Accountability Act of 1995 (HIPPA), I have certain rights to privacy regarding my protected health information (PHI). I understand that this information can and will be used to:

-          Conduct, plan and direct my treatment and follow-up among healthcare providers who may be involved in the treatment directly, or indirectly.

-          Obtain payment from third party.

-          Conduct normal healthcare operations such as quality assessments, and office communications.

I acknowledge the Notice of Privacy Practices (NPP)posted in the reception room and that I have read them or declined the opportunity to read them and understand the NPP contains a more comprehensive description of the uses and disclosure of my Protected Health Information (PHI). I understand that I may, by my request, have a copy of the NPP. By signing this consent, I understand that this office has the right to modify the NPP from time to time and that I may contact this office anytime at:   Gulf Coast Dental Outreach 301 S. Disston Ave., Tarpon Springs FL 34689

I understand that I may request it in writing, to restrict how my private information is used or disclosed to carryout treatment, payment, or health care operations. I 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.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

I understand that this form will be place in my patient chart and maintained for six years.
Patient Name

First NameLast Name
Parent, Guardian, or Legal Rep

First NameLast Name
Signature

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GULF COAST DENTAL OUTREACH DENTALCLINIC PATIENT AGREEMENT
Quality health care is an expensive and time-consuming effort, requiring a commitment of both this Dental Clinic and you, the patient. Gulf Coast Dental Outreach, Inc.is a private, non-profit agency. We are not government operated. Our mission is to make dental care accessible and affordable to the most people possible.

APPOINTMENTS - Phone: 813-5793935, extension I03

We offer patients reduced fees due to agreements with community volunteer dentists, hygienists and dental assistants. Occasionally, dental students, hygiene students and assisting students may be part of the overall team treating you. A Florida licensed dentist will always be present. Patients can expect to have lengthy appointments.

You may be required to bring verification of inc.<>me to your appointment. Please do not bring small children to leave unattended.

PAYMENT - We can only accept cash or checks for payment

CONFIRMING APPOINTMENTS - We must have a confirmation to hold your appointment. We attempt to call everyone two days before their appointment.

24 hours notice is required if you cannot make an appointment. Patients with numerous cancellations or no shows may be discharged from Gulf Coast Dental Outreach.

EMERGENCY APPOINTMENTS - We do not have clinic every day. We are not an Emergency clinic. You may have to go to another office and pay for emergency treatment.

DISCHARGE - Gulf Coast Dental Outreach, Inc. reserves the right to discharge a patient if the patient does not demonstrate commitment to participate in their own oral health. We can help you, but you must also agree to help us help you by taking care of your teeth at home.

Sometimes this also includes changes in lifestyle or diet.

We may refuse treatment to patients when we believe the treatment is beyond our scope of

care of the providers, or if the patient requires so much care that they would be better served in a private dentist's office.

Please remember to give thanks to the people who volunteer their time to provide your health care. We care about our patients and want to continue to serve you in the best way possible. Please treat us with the same respect we treat you.

I understand and agree to the terms of this agreement.
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Welcome to Our Office

MAKE SURE TO FILL OUT ALL BOXES TO FINISH FORM

GULF COAST DENTAL OUTREACH, Inc INITAL CONSENT

Screening Consent Form

Patient Inactivation Policy

Acknowledgement of Receiptand Consent of Notice of Privacy Practices (NPP)

GULF COAST DENTAL OUTREACH DENTALCLINIC PATIENT AGREEMENT