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'iJitolCyeU f©r Rejecting us.To help us meet all your healthcare needs, please fill out this form completely in ink.
Ifyou have any questions or need assistance, please ask us and we will be happy to help.
6|C©1D&Patient Information (Confidential
Name_
SS#/SIN_
Address.
BIrthdate.
City
PatientNumber.
Date
Home Phone ,
State/Prov.
Cell Phone.
Check Appropriate Box: CH Minor CH Single CH Married CI Separated dl Divorced CD WidowedState/
if Student, Name of School/College ,
Patient or Parent/Guardian's Employer.
Business Address
Spouse or Parenf/Guardian's Name
Whom May We Thank for Referring You?
Person to Contact in Case of Emergency
Responsible PartyName of Person Responsible for this Account.
Address
Driver's License;
Employer
Citv_
City_
Employer.
Birthdate.
Work Phone.
Prov.
Work Phone.State/Prov.
Work Phone.
Phone .
Relationshipto Patient
Home Phone .
Cell Phone
Financial institution.
SS#/SiN_
CD Full Time CD PartTime
is this Person Currently a Patient in our Office? CD Yes CD No
Foryour convenience, we offerthe following methods of payment. Please check the optionyou prefer.Paymentinfull at each appointment.
CD Cash n Personal Check Credit Card D VISA D MasterCard D iwish to discuss the office's payment policy.
Insurance Information
Name of Insured
Birthdate
Name of Employer.
Employer Address.
insurance Company
ins. Co. Address
SS#/SiN.
How Much is Your Deductible?.
Union or Local #_
City
Group i
City
How Much Have You Used? ,
Do You Have Any Additlonallnsurance? CD Yes CD No if Yes, Complete the Following
Name of insured.
Birthdate
Name of Employer.
Employer Address.
Insurance Company
ins. Co. Address
SS#/SIN_
How Much is Your Deductible?.
Union or Local #_
City
Group#.
City
How Much Have You Used? .
Over Please
Relationshipto Patient
Date Employed.
Work Phone.State/Prov.
Policy/ID#.State/Prov.
Max. Annual Benefit.
Relationshipto Patient
Date Employed.
Work Phone.State/Prov.
Policy/ID#State/ Zip/Prov. P.C..
Max. Annual Benefit
Patient Medical HistoryPhysician
1. Are you under medical treatment now?
2. Have you ever been hospitalized for any surgicaloperation or serious illness within the last 5 years?Ifyes, please explain
3. Are you taking any medication(s) including non-prescription medicine?Ifyes, what medicationis) are you taking?
4. Have you overtaken Fen-Phen/Redux?
5. Have you ever taken Fosamax, Boniva,Actonel or anycancer medications containing hisphosphonates?
6. Have you taken Viagra, Revatio, Cialis or Levitra inthe last 24 hours?
7. Do you use tobacco?
8. Do you use controlled substances?
9. Doyou have or have you had any of the following?
Office Phone,Yes No
• •
Date of Last Exam
• •
• •
• •
• •
• •
• •
• •
10. Are you wearing contact lenses?
11. Areyou allergic to or have you had any reactions to the following?LocalAnesthetics (e.g. Novocain)Penicillin or any other AntibioticsSulfa Drugs
Barbiturates
Sedatives
Iodine
AspirinAny Metals (e.g. nickel, mercury, etc.)Latex Rubber
Other
12. Doyou have a persistent cough or throat clearing notassociated with a known illness (lasting more than 3 weeks)?
13. Women Only:Are you pregnant or think you may he pregnant?Are you nursing?Are you taking oral contraceptives?
Yes No
• •
•••••
•••••
• •• ••••
•••
• •
• •• •• •
Yes No Yes No Yes No
High Blood Pressure • • Heart Disease • • Chest Pains • •Heart Attack • • Cardiac Pacemaker • • Easily Winded • •Rheumatic Fever • • Heart Murmur • • Stroke • •Swollen Ankles • • Angina • • Hay Fever/Allergies • •Fainting/Seizures • • Frequently Tired • • Tuberculosis • •Asthma • • Anemia • • RadiationTherapy • •Low Blood Pressure • • Emphysema • • Glaucoma • •Epilepsy/Convulsions • • Cancer • • Recent Weight Loss • •Leukemia • • Arthritis • • Liver Disease • •Diabetes • • Joint Replacement or Implant • • Heart Trouble • •Kidney Diseases • • Hepatitis/Jaundice • • Respiratory Problems • •AIDS or HIV Infection • • Sexually Transmitted Disease • • MitralValve Prolapse • •Thyroid Problem • • Stomach Troubles/Ulcers • • Other • •
Patient Dental HistoryName of Previous Dentist and Location Date of Last Exam_
Yes No Yes No
1. Doyour gums bleed while brushing or flossing? • • 8. Do you have frequent headaches? • •2. Are your teeth sensitive to hot or cold liquids/foods? • • 9. Doyou clench or grind your teeth? • •3. Are your teeth sensitive to sweet or sour liquids/foods? • • 10. Doyou hite your lips or cheeks frequently? • •4. Do you feel pain to any of your teeth? • • 11. Haveyou ever had any difficult extractions in the past? • •5. Doyou have any sores or lumps in or near your mouth? • • 12. Have you ever had any prolonged bleeding
8. Have you had any head, neck or jaw injuries? • • following extractions? • •7. Have you ever experienced any of the following 13. Have you had any orthodontic treatment? • •
problems in your jaw? 14. Doyou wear dentures or partials? • •Clicking • • If ves. date of alacement
Pain (joint, ear, side efface) • • 15. Have you ever received oral hygiene instructions
Difficulty in opening or closing • • regarding the care of your teeth and gums? • •Difficulty in chewing • • 18. Do you like your smile? • •
Authorization and Release
1certifythat 1have read and understandthe above information to the best ofmyknowledge. to the dentist or dental groupinsurance benefitsotherwise payableto me.1understandThe above questions have been accurately answered. I understand that providing incorrectinformation can be dangerous to myhealth. I authorize the dentist to release any informationincluding the diagnosis and the records of any treatment or examination rendered tome or mychild during the period ofsuch Dental care to third partypayors and/or healthpractitioners. I authorize and request myinsurance companyto pay directly
that mydental insurance carrier maypay less than the actual bill for services. I agree to beresponsible for payment ofallservices renderedon mybehalf or my dependents.
XSignatureof patient(or parent/guardian ifminor)
Doctor's Comments
Signature Date
S 1998 PATTERSON OFFICE SUPPUES 1.800.637.1140 0561993/17694
Acknowledgement of Receipt ofNotice of Privacy Practices
For
R. Nicholas Cost, D.D.S., PA318 W. Farley Ave.Laurens, SO 29360
I hereby acknowledge that I have received the Notice of Privacy Practices for theabove office.
Signature; Patient's Name / Personal Representative (as defined by HIPAA) Date
Description of Personal Representation and please attach copy of documentation.
Documentation of "Good Faith" Attempt to get acknowledgementsignature.
• Document presented to patient, but patient refused to signacknowledgement.
• Patient presented with an emergency situation and there was no time togive the Notice or receive a signature. Attempt to get give the Notice, andget any acknowledgement will be handled as soon as possible.
• Documentation was presented to the patient but a communication failureprevented us from receiving the acknowledgement.
• The documentation was mailed to the patient but never returned to us.
• Other
Employee preparing document Date
Employee signature
Authorization- Compound
This authorization form permits:Confident Smiies of Laurens
318 West Farley AveLaurens, SO 29360
to use or disclose protected health information listed in the Description section below tothe Entity or Person listed in the Receiving Entity section for the following patient:
NameAddressCity/State/ Zip
Birth Date
Receiving Entity: Please check the boxesfor those entities or persons you wish toget the described information about you.
Description of information to be given tochecked Entity or Person.
Home
#
• Appointment time• Results of lab test or x-rays• Other
Business
#
• Appointment time• Results of lab test or x-rays• Other
Cell phone#
• Appointment time• Results of lab test or x-rays• Other
Employer • Appointment or absenteeinformation
• Return to work or schoolinformation
School
Spouse (Provide name) • Family billing information• Financial information
• Medical information- please list
Parent (Provide name) • Family billing information• Financial information
• Medical information- please list
Other (Provide name) • Financial information
• Medical information- please list
Relationshio-
Facebook • Name
• Photo in the event of winning acontest
Purpose
The purpose of this authorization is to meet the patient's request for informationdisclosures and uses.
Expiration date or event: This authorization shall be enforce until revoked by thepatient or
Verification method or code: This practice will verify the identity of any entity requestingprotected health information. Verification information may include:
Last 4 digits of SSN
Rights of the Patient
I understand that I have the right to refuse to sign this authorization and that mytreatment will not be conditioned on signing.
I understand that I have the right to revoke this authorization at any time by sending awritten notification to the address listed at the top of this form I understand that arevocation is not effective in cases where the information has already been used ordisclosed but will be effective going forward.
I understand that information used or disclosed as a result of this authorization may besubject to redisclosure by the recipient and may no longer be protected by federal orstate law.
Date
Signature of Patient or Personal Representative (as defined by HIPAA)
Description of Personal Representative's Authority (attach necessary documentation)
********************************************************************************************
Office Use Only .
Receiving Employee Date received
• Copy given to patient
Medicaid Broken Reservation Policy
> Our office requires 48 HOUR notice if you are unable to attend your dental
reservation.
> We make multiple attempts to confirm your dental reservation. YOU MUST
CONFIRM YOUR RESERVATION. If your reservation is not confirmed 48 HOURS
in advance we reserve the right to give your reservation time away to another
patient.
Failure to give 48 hour-notice will result in the following:
1.) We will report your failed attendance to SC Medicaid—^WHICH MAY CAUSE YOU TO LOSE
YOUR MEDICAID INSURANCE!
2.) Patients who violate this policy 2 TIMES in a calendar year will be DISMISSED from our office.
Emergencies happen! We will allow special consideration for family emergencies (Ex. Sickness,Death in the Immediate Family)
Guardian/Patient Signature: Date:
Broken Reservation/Last Minute Cancellation Policv
> Our office requires 48 HOUR notice if you are unable to attend your dental
reservation.
> We make multiple attempts to confirm your dental reservation. YOU MUST
CONFIRM YOUR RESERVATION. If your reservation is not confirmed 48 HOURS
in advance we reserve the right to give your reservation time away to another
patient.
Failure to give 48 hour-notice will result in the following:
1.) A fee of $50 is charged for patients who miss or cancel more than 1 TIME in a calendar year.
2.) Patients who violate this policy 3 TIMES in a calendar year will be DISMISSED from our
office.
Emergencies happen! We will allow special consideration for family emergencies (Ex. Sickness,Death in the Immediate Family)
Guardian/Patient Signature: Date:
Confident Smiles of Laurens318 FARLEY AVENUE | LAURENS SO, 29360 | (864)766-4633
Written Financial Policy
Thank you for choosing Confident Smiles of Laurens. Our mission is to serve the residents of the Upstate, educatingand empowering them to change their lives via a healthy, confident smile. An important part of our mission is makingthe cost of comprehensive care easy and affordable for our patients by offering several payment options.
Payment Options:
You can choose from:
> Cash, MasterCard®, American Express®, Discover Card® orCareCredit®
> Monthly Payment Options^ from CareCredit Healthcare Credit Card or our In-House Payment Plan (3 or6 months) are also available
o Allows you to pay over time
o Interest Free Options
o No annual fees or pre-payment penalties
We require payment prior to the completion of your treatment. Ifyou choose to discontinue care before treatment iscomplete, no refund will be provided.
For larger, more comprehensive treatment plans of $1000 or more, a 10% deposit is required to secure your initialtreatment reservation.
We offer a 5% accounting courtesy adjustment to patients who pay for their treatment on or before the day ofservice with Cash for treatments of $1000 or more.
We also offer in-house financing for treatment plans between $500 and $7000.
A finance charge not exceeding 1.5% per month may be applied to that portion of the account balance not receivedwithin 30 days of receiving a mailed account statement from our office.
Please remember we are not party to the contract that is between you and your dental insurance carrier. Howeverwe are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement for yourtreatment.^
A fee of $50 is charged for patients who miss or cancel more than 1 time in a calendar year without 48-hour notice.
Confident Smiles of Laurens charges $35 for returned checks.
Ifyou have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want orneed.
Patient, Parent or Guardian Signature Date
Patient Name (Please Print)
^Subject to credit approval
^However, If we do not receive payment from your insurance carrier within 60 days, you will be responsible for payment of your treatmentfees and collection of your benefits directly from your insurance carrier.
