DOWELL DENTAL GROUP
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DOWELL DENTAL GROUP WELCOME TO OUR PRACTICE! (Please Print) Today’s date: Appointment date: PATIENT INFORMATION Patient’s last name: First: Middle: q Mr. q Mrs. q Miss q Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your legal name? If not, what is your legal name? (Former name): Birth date: Age: Sex: q Yes q No / / q M q F Street address: Social Security no.: Home phone no.: ( ) P.O. box: City: State: ZIP Code: Cell Phone: E-mail address: Occupation: Employer Name and Address: Employer phone no.: ( ) Referred by: Reason for coming to our practice: q Family q Friend (name) q Close to home/work q Yellow Pages q Other Other family members seen here: INSURANCE INFORMATION (PLEASE GIVE YOUR INSURANCE CARD TO THE RECEPTIONIST) Person responsible for bill: Birth date: Address (if different): Home phone no.: / / ( ) Is this person a patient here? q Yes q No Social Security Number: Occupation: Employer: Employer address: Employer phone no.: ( ) Is this patient covered by DENTAL insurance? q Yes q No Name of insurance company: Subscriber’s name: Subscriber’s S.S. no.: Birth date: Group no.: Policy no.: / / Patient’s relationship to subscriber: q Self q Spouse q Child q Other Name of secondary DENTAL insurance (if applicable): Secondary Insurance Company: Group no.: Subscriber’s ID# Subscriber’s name: Subscriber’s S.S. no.: Birth date: / / Patient’s relationship to subscriber: q Self q Spouse q Child q Other IN CASE OF EMERGENCY Name of local friend or relative (not living at same address): Relationship to patient: Home phone no.: Work phone no.: ( ) ( ) The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Stephen C. Dowell DDS, Inc. or insurance company to release any information required to process my claims. I also understand that Dr. Dowell has the right to charge for broken appointments when notice is not given within 2 business days. Signature of Responsible Party : _____________________________________________ Date:______________________________
Transcript of DOWELL DENTAL GROUP
DOWELL DENTAL GROUP WELCOME TO OUR PRACTICE!
(Please Print)
Today’s date: Appointment date:
PATIENT INFORMATION Patient’s last name: First: Middle: q Mr.
q Mrs. q Miss q Ms.
Marital status (circle one)
Single / Mar / Div / Sep / Wid
Is this your legal name? If not, what is your legal name? (Former name): Birth date: Age: Sex:
q Yes q No / / q M q F
Street address: Social Security no.: Home phone no.:
( )
P.O. box: City: State: ZIP Code:
Cell Phone: E-mail address:
Occupation: Employer Name and Address: Employer phone no.:
( )
Referred by: Reason for coming to our practice:
q Family q Friend (name) q Close to home/work q Yellow Pages q Other
Other family members seen here:
INSURANCE INFORMATION (PLEASE GIVE YOUR INSURANCE CARD TO THE RECEPTIONIST)
Person responsible for bill: Birth date: Address (if different): Home phone no.:
/ / ( )
Is this person a patient here? q Yes q No Social Security Number:
Occupation: Employer: Employer address: Employer phone no.:
( )
Is this patient covered by DENTAL insurance? q Yes q No Name of insurance company:
Subscriber’s name: Subscriber’s S.S. no.: Birth date: Group no.: Policy no.:
/ /
Patient’s relationship to subscriber: q Self q Spouse q Child q Other
Name of secondary DENTAL insurance (if applicable): Secondary Insurance Company: Group no.: Subscriber’s ID#
Subscriber’s name: Subscriber’s S.S. no.: Birth date:
/ /
Patient’s relationship to subscriber: q Self q Spouse q Child q Other
IN CASE OF EMERGENCY Name of local friend or relative (not living at same address): Relationship to patient: Home phone no.: Work phone no.:
( ) ( )
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Stephen C. Dowell DDS, Inc. or insurance company to release any information required to process my claims. I also understand that Dr. Dowell has the right to charge for broken appointments when notice is not given within 2 business days. Signature of Responsible Party : _____________________________________________ Date:______________________________
Dowell Dental Group General - Restorative - Cosmetic
549 2ND Street N.W. Carrollton, OH 44615 (330) 627-5005 25 3rd St. Carrollton, OH 44615 (330) 627-5569
817 E. Lincolnway Minerva, OH 44657 (330) 868-5001 615 N. Market St. Minerva, OH 44657 (330) 868-5080
328 Race St., Dover OH 44622 (330) 364-1414 www.dowelldental.com
Patient PHI Authorization Form
I, _____________________________ ______________ (Please print) Date of Birth
hereby give Dr. Stephen C Dowell, DDS, Inc. permission to discuss my personal medical information with the following individual(s): ________________________________ _______________ __________________
Name Date of Birth Relationship to Patient ________________________________ _______________ __________________
Name Date of Birth Relationship to Patient ________________________________ _______________ __________________
Name Date of Birth Relationship to Patient ________________________________ _______________ __________________
Name Date of Birth Relationship to Patient I understand that the information that may be discussed includes, but is not limited to: my health history, diagnostic results, plan of care and medical financial information unless otherwise restricted here: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ I understand that this authorization will remain in effect until terminated by myself in writing. ______________________________________________ ___________________
Patient/Guardian Signature Signature Date PHI FORM
PRINT PATIENT NAME _____________________________________________________________
*YouMayRefusetoSignThisAcknowledgment*
Ihavereceivedacopyofthisoffice’sNoticeofPrivacyPractices.PrintName:____________________________________________________________________
Signature:_____________________________________________________________________
Date:_________________________________________________________________________
ForOfficeUseOnly______________________________________________________________________________WeattemptedtoobtainwrittenacknowledgementofreceiptofourNoticeofPrivacyPractices,butacknowledgementcouldnotbeobtainedbecause:
Individualrefusedtosign
Communicationsbarriersprohibitedobtainingtheacknowledgement
Anemergencysituationpreventedusfromobtainingacknowledgement
Other(PleaseSpecify)
Reproductionofthismaterialbydentistsandtheirstaffispermitted.Anyotheruse,duplicationordistributionbyanyotherpartyrequiresthepriorwrittenapprovaloftheAmericanDentalAssociation.Thismaterialisforgeneralreferencepurposesonlyanddoesnotconstitutelegaladvice.ItcoversonlyHIPAA,nototherfederalorstatelaw.Changesinapplicablelawsorregulationsmayrequirerevision
DOWELL DENTAL GROUP
DOWELL DENTAL GROUP FINANCIAL GUIDELINES
ChangingtheWorldOneSmileataTime_________________________________________________________________
WELCOME and THANK YOU for choosing our team as your dental health provider. Our financial goal is to offer state of the art treatment at an affordable investment leading to improved oral health. We base our recommendations on the needs of our patients rather than the limitations of insurance
benefits. Our practice submits your dental insurance claim as a courtesy. All fees incurred in treatment are your responsibility regardless of your insurance coverage.
Please indicate below your preferred method of payment: ____ Cash ____ Personal Check ____ Credit Card (MC, VISA, DISCOVER) ____ Care Credit upon approval @ carecredit.com (we are happy to assist you if needed)
___________________________________________________________________________
CONSENT TO FINANCIAL GUIDELINES
I have read, understand and agree to the above terms and conditions. I authorize my insurance company to pay my dental benefits directly to the Dowell Dental Group. I understand that responsibility for payment for all my dental treatment provided in this office for myself and/or my dependents is mine, due and payable at the time services are rendered, unless other written and signed financial arrangements have been made. _____________________________________________________________ _________________________
Patient signature/Parent of Dependent Child Date
Note: Returned checks will be subject to additional fees. In the case it becomes necessary for our practice to enlist a collection service and/or legal assistance, you will be responsible for any collection and/or legal fees incurred.
