Patient Acquaintance Form

Office Financial Policy:

In an effort to prevent any misunderstanding, we have set forth the following financial policy:

Full payment is expected at the time of service unless other written arrangements have been made and agreed upon prior to your appointment.
The copay presented on the day of service is just an estimate and is subject to change. In the event there is an outstanding balance after the claim is processed, you are responsible for all charges whether or not paid by insurance.
If an appointment is broken or cancelled with less than 24 business hours’ notice, a $25.00 charge per appointment will be applied to your account.
A deposit will be required to reschedule appointments after two or more consecutive cancellations of the same appointment. The deposit will be applied to copay if patient arrives to the appointment or will be forfeited if cancelled or broken again.
It is understood and agreed that in the event that any outstanding balance has to be referred to a collection agent or attorney for recovery, the patient will be fully responsible for any costs, including but not limited to attorney’s fees. A social security number is required on a family file in the case we need to refer to collection agency.

Name of Responsible Party*

Social Security Number

Please list full name of each family member that you are responsible for*

Please fill out the following information if you have Dental Insurance:

(Please make sure that all information is accurate and complete. A social security number is required to process claims. It will greatly expedite the processing of your claim. Thank You.)

Primary Insurance Information

Policy Holder Name

Date of Birth

Name of Insurance Company

Subscriber ID Number & SSN

Employer

Group Number

Insurance Company Phone Number

List of dependents covered under primary insurance plan

Do you have dual dental insurance?*

Yes

Secondary Insurance Information

Policy Holder Name*

Date of Birth*

Name of Insurance Company*

Subscriber ID Number & SSN*

Employer*

Group Number*

Insurance Company Phone Number*

List of dependents covered under primary insurance plan*

Acknowledgement Form Notice of Privacy Practices:

THIS NOTICE DESCRIBES HOW MEDICAL/PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.

Summary:

By law, we are required to provide you with our Notice of Privacy Practices (NPP). The Notice describes how your medical information may be used and disclosed by us. It also tells you how you can obtain access to this information.

As a patient, you have the following rights:

The right to inspect and copy your information
The right to request corrections to your information
The right to request that your information be restricted
The right to request confidential communication
The right to a report of disclosures of your information
The right to a paper copy of this notice

We want to assure you that your medical/protected health information is secure with us. The Notice contains information about how we will ensure that your information remains private.

Acknowledgement of Notice of Privacy Practices

I hereby acknowledge that I have received a copy of this practice’s NOTICE OF PRIVACY PRACTICES. I understand that if I have questions or complaints regarding my privacy rights that I may contact the office directly. I further understand that the practice will offer me updates to the NOTICE OF PRIVACY PRACTICES should it be amended, modified or changed in any way.

Print Name*

Signature*

Reset

Patient Information:

Parent/Guardian 1 Information:*

Parent/Guardian 2 Information:

Medical History:

Dental History:

Oral Health Habits:

Office Financial Policy:

Please fill out the following information if you have Dental Insurance:

Acknowledgement Form Notice of Privacy Practices: