Willowcreekdental.net

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize Willow Creek Dental to use and disclose my protected health information to carry out the following:  Treatment (including direct or indirect treatment by other healthcare providers involved in  Obtaining payment from third-party payers (e.g. my insurance company);  The day-to-day healthcare operations of Willow Creek Dental. I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that Willow Creek Dental reserves the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that Willow Creek Dental is not required to agree to these requested restrictions. However, if Willow Creek Dental does agree, then Willow Creek Dental is bound to comply with this restriction. I understand that I may revoke this consent in writing at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected. Signed this ________day of ____________________, 20_____. 6660 Timberline Road, Suite 220, Highlands Ranch, Colorado 80130 Telephone: 303.779.2797 Facsimile: 303.779.2687 It is YOUR responsibility to be familiar with your insurance policy. Please make certain that you know what dental benefits are covered under your dental insurance policy. You will want to be familiar with your deductibles, co-payments, and percentages of coverage at the time services are rendered. While Willow Creek Dental is happy to submit your claims to your insurance company on your behalf, payment for dental services provided by Willow Creek Dental are the responsibility of the patient (or parent/legal guardian if patient is under 18 years of age). Please remember, most policies do not cover 100% of the fee of most procedures. PARENTS: If services are provided to a minor child in which the parents are divorced, regardless of what the divorce decree may state, both parents are equally responsible for dental services provided to a minor child. The divorce decree is a civil agreement between the two parties and not Willow Creek Dental. SPOUSES: You are equally responsible for the others dental debt. I UNDERSTAND THAT MY INSURANCE POLICY IS A CONTRACT BETWEEN ME (THE PATIENT) AND THE INSURANCE COMPANY. The medical provider is not a party to that contract. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES THAT HAVE BEEN INCURRED FOR DENTAL SERVICES RENDERED IN MY BEHALF OR THAT OF MY MINOR CHILD OR SPOUSE. ANY BALANCE REMAINING AFTER MY CO-PAYMENTS AND INSURANCE PAYMENTS ARE ALSO MY RESPONSIBILITY. Signature of Patient or Responsible Party 6660 Timberline Road, Suite 220, Highlands Ranch, Colorado 80130 Telephone: 303.779.2797 Facsimile: 303.779.2687 MEDICAL HISTORY
PATIENT NAME _______________________________________________ Birth Date _____________________________________ Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the Have you ever been hospitalized or had a major operation? Have you ever had a serious head or neck injury? Are you taking any medications, pills, or drugs? Do you take, or have you taken, Phen-Fen or Redux? Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Are you allergic to any of the following? Do you have, or have you had, any of the following? Have you ever had any serious illness not listed above? To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can bedangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
SIGNATURE OF PATIENT, PARENT, or GUARDIAN __________________________________________________ DATE ______________________

Source: http://www.willowcreekdental.net/docs/NEW%20PATIENT%20FORMS%20CHILD.pdf