Oil City Dental

Oil City Dental

Patient Registration Form
Name

First NameMILast Name
Date of Birth

MonthDayYear
Date
Gender
Social Security Number (Used for insurance purposes)
Address

Street Address

Street Address Line 2

CityState / Province

Zip Code
Email Address
example@example.com
Mobile Phone Number
Home Phone Number
Responsible Party Information

(If different than above)
Name

First NameMILast Name
Date of Birth

MonthDayYear
Date
Social Security Number (Used for insurance purposes)
Mailing Address
How did you hear about our office
Emergency Contact
Name

First NameLast Name
Phone Number
Relationship to Patient

Dental Insurance
Policy Holder's First Last Name
Policy Holders Date of Birth

MonthDayYear
Date
Name of Insurance Company
Policy Number/Member Number/Subscriber ID
Group Number
Name of Employer
Insurance Company Phone Number
Do you have a secondary dental insurance policy?
If yes, please provide secondary dental insurance information to an office team member.
Patient Signature

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Rel to Patient

Patient Financial Policy Agreement
Thank you for choosing Oil City Dental as your dental care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our financial policy which we require that you read and sign prior to any treatment.

Before any treatment is performed, we will present to you at your request (assuming your insurance information is correct) an ESTIMATE of what your insurance will pay. This is ONLY AN ESTIMATE. As a courtesy, we will file your insurance claims on your behalf. However, it is the responsibility of the primary account holder to pay any balance the insurance company does not cover. It is the patient's responsibility to update us with insurance changes, which can/will affect treatment estimates.

Please be aware of the following:
- Payment is due at the time of treatment.
- We accept, cash, check, VISA, MasterCard, and Discover.
- We offer third-party financing through CareCredit.
- Accounts not paid in full by the end of each month will accrue a billing fee of 1.75% per month (21% annually) .
- A fee of $80 will be charged to your account for appointments missed or canceled with less than 24-hour notice.
- After three missed appointments, we reserve the right to dismiss you from the practice.
I, the undersigned client/guardian, agree to pay for all services rendered and/or goods sold to me or my ward immediately upon demand. I further agree that in the event of non-payment of any amount due under this agreement, I will pay interest thereon at the rate of 1.75% per month (21% annually) and pay all reasonable attorney fees and court costs that may be incurred. I agree that in the event this agreement is assigned to an agency for collection, I agree to pay an additional collection fee of 35% of the unpaid balance due.
Authorization for Release of Information

I authorize Oil City Dental to release any information, including the diagnosis and records of the treatment or examination rendered to me during the period of such dental care, to third-party payers and/or other healthcare providers.

I authorize and hereby request my insurance company to pay insurance benefits otherwise payable to me directly to the dentist (Oil City Dental, LLC

I understand that my medical and/or dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered for myself and my dependents.
Patient Signature

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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 duties 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 takes effect / / 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 changes in our privacy practices and the new terms of our notice are effective 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.

You may request a copy of our notice at any time. For more information about our practices or additional copies of this notice please contact us using the information listed at the end of this notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment payment and healthcare operations. For example:

TREATMENT: We may use or disclose your health information to a physician or other health care provider providing treatment to you.

PAYMENTS: 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 healthcare operations. Healthcare operations include quality assessment and improvement activities. Reviewing the competence or qualifications of health care professionals, evaluating practitioners and provider performance conducting training programs accreditation, certification, licensing or credentialing activities.

YOUR AUTHORIZATION: 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 authorize us, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while in effect. Unless you give us written authorization we cannot use or disclose your health information for any reason except those described in this notice.

TO YOUR FAMILY AND FRIENDS: We must disclose your health information to you as described in the patient rights section of this notice. We may disclose your health information to a family member, friend, or another person to the extent necessary to help with your health care or with payment for your healthcare, 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 locating a family member your personal representative or another person responsible for the care of your location, your general condition, or death. If you are present then prior to the use or 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 judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and our experience with common practices 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 communications without your written

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, 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 health or safety or the health or safety of others.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
** You may refuse to sign this acknowledgment **
I received a copy of this office's Notice of Privacy Practices.

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Women Only
Are you pregnant?

YesNo
If yes, number of weeks:
Are you taking birth control pills or hormonal replacement?

YesNo
Are you nursing?

YesNo

By signing below, I certify that all the above information is true to the best of my knowledge. I understand the importance of this information and that the practice will rely on this information for the treatment. I will not hold the practice or any member / staff of the practice, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.
Signature of Patient or Responsible Party

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Today's Date

MonthDayYear
Date

Records Release
Patient Name to Transfer

First NameLast Name
Patient DOB

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Mailing Address (Street/City/State/Zip Code)
Other Family Members to Transfer
Dentist or Practice Name (to send records to/from)
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.
Fax
Please enter a valid phone number.
Email
example@example.com
PLEASE FORWARD THE FOLLOWING: X-RAYS, COMPLETE DENTAL RECORDS (INCLUDING CHART NOTES, PROBING DEPTH CHART, PROPHY OR PERIO HISTORY)
If you are a patient's personal representative (Parent/Guardian), Relationship to Patient:
I certify that the above information is true and correct.
Signature

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Date

MonthDayYear
Date
Should be Empty:

	Yes	No	Don't Know
AIDS or HIV Infection
Alcohol / Drug Abuse
Artificial Joint(s)
Blood Transfusion
Cancer
Cardiovascular Disease
Chemo or Radiation Treatment
Congestive Heart Failure
Frequent Dry Mouth / Sjogren
G.E. Reflux / Persistent Heartburn
Heart Murmur
High Blood Pressure
Low Blood Pressure
Osteoporosis
Other Congenital Heart Defects
Pacemaker
Rheumatic Fever
Seizures
Sexually Transmitted Diseases
Sleep Disorder
Snoring
Stroke
Tuberculosis

	Yes	No	Don't Know
Amoxicillin
Aspirin
Keflex
Latex/Rubber
Penicillin
Sulfa
Tetracycline

Responsible Party Information

Emergency Contact

Dental Insurance

Patient Financial Policy Agreement

Notice of Privacy Practices

USES AND DISCLOSURES OF HEALTH INFORMATION

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Medical History

Medical Questionnaire

Women Only

Records Release