pinelakesendo.com-PATIENT INFORMATION

Patient's Name:
Date of Birth:

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Date
Person Responsible For Account
Relationship to Patient
Address

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Phone Numbers:
Home
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Cell
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Work
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HomeCellWork
Social Security #
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Referring Dentist
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PRIMARY INSURANCE INFORMATION
Person Responsible or Policy Holder
Relationship to Patient
Insured's Date of Birth

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Date
Dental Insurance Provider
Group #
ID #/SSN
Address

Street Address

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Phone
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Employer

SECONDARY INSURANCE INFORMATION
Person Responsible or Policy Holder
Relationship to Patient
Insured's Date of Birth

MonthDayYear
Date
Dental Insurance Provider
Group #
ID #/SSN
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Employer

FINANCIAL POLICY
Thank you for choosing us as your healthcare provider. We never want you to be surprised by the cost of your treatment. Please verify the approximate cost of your treatment prior to being seen. You will be responsible for payment at the time of treatment.We accept cash, check, Visa, Mastercard, Discover, and American Express. CareCredit may be an option for you as well. Please ask our patient coordinators for further information if you are interested.

For patients with insurance coverage, copayment is due at the time of treatment.We are happy to assist you in filing your dental insurance claim. We will give you the best estimate we are able to determine from your insurance provider; however, please understand that our calculations are strictly ESTIMATES and there is no guarantee that your insurance company will reimburse us according to these estimates. Your insurance policy is a contract between you and your insurance company, and we are not a party to that contract. You are responsible for any portion of the treatment fee that your insurance company does not pay, for any reason.

A finance charge is computed at a periodic rate of 1.5% monthly (annual percentage rate of 18%) on any unpaid balance over 90 days. A fee of $35 will be charged for all returned checks. Any attorney or collection fees incurred due to delinquency in payment will also be charged to the patient.

I have read the Financial Policy and understand my financial responsibility for dental services provided. I hereby authorize payment of the dental insurance benefits otherwise payable to me directly to Pine Lakes Endodontics and authorize release of any information relating to a claim.
Patient Signature
Date

MonthDayYear
Date

Consent for Use & Disclosure of Health Information
I pledge I have read/received a copy of this practice's Notice of Privacy Practices. I understand that, by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.
Name (Please print)
Date of Birth:

MonthDayYear
Date
Signature:
Date:

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Date
If this consent is signed by a personal representative on behalf of the patient, complete the following:
Personal Representative's Name:
Relationship to Patient:
Additional Release of Information:
I authorize the additional release of information including the diagnosis, records, treatment rendered to me, and claims information. The information may be released to:
Spouse/Partner:
Children:
Other:
DO NOT RELEASE TO ANYONE ELSE
My HomeMy CellOther:
Leave a detailed messageLeave a message asking me to return your call
Revocation of Consent:
I revoke my consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations. I understand that revocation of my consent will not affect any action you took in reliance on my consent before you received this written Notice of Revocation. I also understand that you may decline to treat me after I have revoked my consent.
Signature:
Date:

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Record of Discussion and Informed Consent for CВСТ
A CBCT scan (also called cone beam computerized tomography) is an x-ray technique that is similar to a medical CT scan. It produces images of your body that depict internal structures in cross-section rather than the overlapping images typically produced by conventional dental x-ray exams.

A conventional x-ray of your mouth limits your dentist to a two-dimensional (2D) view. Diagnosis and treatment planning can require a more complete understanding of the complex three-dimensional (3D) anatomy of your tooth. A CBCT scan can provide this crucial 3D information to accurately diagnose and treat conditions which may not be fully understood otherwise.

Risks: CBCT scans, like other dental x-rays, expose you to a very small amount of radiation. The dose is approximately the same as the following background radiation equivalents: 1 day for upper teeth, 3 days for lower front teeth and 5 days for lower back teeth. The alternative to a CBCT scan is a conventional dental x-ray; however, this has the limitations previously noted.

While parts of your anatomy beyond your mouth and jaw may be seen on the scan, your dentist is not a physician or specialist to make assessments concerning the anatomy beyond your mouth or jaw. Ifthe scan raises a question as to something unusual outside the mouth or jaw, your dentist may refer you to a physician or another specialist for evaluation. In such an event, our office can place the image on a DVD. CBCT images do not show most soft tissues or fluids, so some problem areas may have to be imaged with other methods.

Women: CBCT scans are not recommended for routine use on pregnant women due to the potential danger to the fetus.
I am not pregnantI am pregnantI am unsure if I am pregnant
The CBCT scan is not included as part of my examination/consultation, and I understand that there is an additional fee. This can be billed to my insurance, if applicable, but there is no guarantee that it will be a covered service.

I certify that I have read this consent form and understand the imaging to be performed, as well as the risks, benefits and alternatives. I acknowledge that I have had the opportunity to discuss this procedure and have had all questions answered to my satisfaction. I consent to a CBCT scan to aid in diagnosis and/or treatment.
Patient signature
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Date
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PRIMARY INSURANCE INFORMATION

SECONDARY INSURANCE INFORMATION

FINANCIAL POLICY

MEDICAL HISTORY

Whom may we notify in case of an emergency?

Consent for Use & Disclosure of Health Information

Additional Release of Information:

Revocation of Consent:

Record of Discussion and Informed Consent for CВСТ