The Dentist of Summerlin...The Dentist of Summerlin Patient Information George A. Davis Jr., D.D.S....

Click here to load reader

  • date post

  • Category


  • view

  • download


Embed Size (px)

Transcript of The Dentist of Summerlin...The Dentist of Summerlin Patient Information George A. Davis Jr., D.D.S....

  • The Dentist of Summerlin

    Patient Information

    George A. Davis Jr., D.D.S.

    Date:_______________ Name __ Preferred Name

    Last First Middle Initial

    Social Security Number______________________________

    Cell Phone ( ) Would you like a reminder text? YES or NO

    Home Phone ( ) Work Phone ( )

    E-Mail________________________________________ Would you like reminder emails? YES or NO

    What is the best way to contact you? Please circle all that apply: HOME WORK CELL TEXT EMAIL

    Address Minor Single Married Separated

    City State Zip Divorced Widowed Partnered for years

    Sex M F Age Birth Date

    Patient Employer/School Occupation

    Whom may we thank for referring you?

    In case of an emergency who should be notified? Phone ( )

    Dental Insurance

    Please present insurance card for verification

    Primary Insurance Information Policy Holder’s name Relation to Patient

    Birth Date Social Security OR member ID #

    Address (If different than patient’s)

    Employer Plan or Group#

    Dental Insurance Company Name:

    Address: Phone #:

    Insurance Authorization I certify that I, and/or my dependent(s) assign all insurance benefits, if any, directly to

    Dr. George Davis, otherwise payable to me for services rendered. I understand that I am financially responsible for all

    charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

    Print name of Patient, Parent or Guardian Date

    Signature of Patient, Parent or Guardian

    Notice of Privacy Practices

    I acknowledge that I have reviewed the notice of privacy practices from George A. Davis, Jr. DDS and I authorize

    the use of my health information to carry out treatment, payment activities, and health care operations.

    Name _________________________Signature ______________________________Date___________________


    If yes, please explain:

    To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous 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:

    Medical History Although dental personnel primarily treat the area 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 following questions.

    Name: Phone: Date of last medical exam:

    What was the exam for? Current Physician:

    Have you ever been hospitalized or had a major operation? Are you under the care of a physician? Have you ever had a serious head or neck injury? Are you taking any medications or supplements? If yes please list, the dose and how often: (use back of paper if needed)

    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 on a special diet? Do you use Tobacco? Do you use controlled substances?

    Women Y N Are you pregnant or trying to get pregnant? Are you taking contraceptives? Are you nursing?

    Are you allergic to any of the following?

    Aspirin Penicillin Local Anesthetics Acrylic Codeine Metal Latex Sulfa Drugs Other

    Y N

    Acid Reflux AIDS\HIV Positive Alzheimer’s Disease Anaphylaxis Anemia Angina Arthritis\Gout Artificial Heart Valve Artificial Joint: What Joint? When? Asthma Blood Disease Blood Transfusion Breathing Problem Bruise Easily Cancer Type? Chemotherapy When? Chest Pains Cold Sores\Fever Blisters Congenital Heart Disorder Convulsions Cortisone Medicine Diabetes Drug Addiction Dry Mouth Easily Winded Emphysema

    Epilepsy\Seizures Excessive Bleeding Excessive Thirst Fainting Spells\Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack\Failure Heart Murmur Heart Pace Maker Heart Trouble\Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Inflammatory disease Type? Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease

    Mitral Value Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments When? Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Sleep Apnea Did you wear a c-pap? Y N Spina Bifida Stomach\Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice




















  • 1930 Village Center Circle Suite #12 Las Vegas, NV 89134

    Phone - (702) 562-2322 Fax – (702) 562-9610

    Email – [email protected]

    Financial Policy

    At the office of Dr. Davis, we believe that you deserve the best care. That’s why we always present you with the best dental solution possible

    to treat your personal situation. Each year we provide outstanding dental care to hundreds of patients. Some have dental benefits but some

    don’t. If you have dental benefits, congratulations! You are very fortunate. Here are some important things you should know:

    Please initial in highlighted areas:

    ______ Your dental benefits are based upon a contract made between your employer and an insurance company. If you have any questions

    regarding your dental benefits please contact your employer or insurance company directly. Dental benefit plans will never pay for

    completion of your dental care. It is only meant to assist you.

    ______ We currently accept most PPO (Preferred Provider Organizations) private/employer care insurance plans. This means that we work

    with literally thousands of companies. Although we can maintain computerized histories of payment by a given company, they do change;

    therefore, it is impossible to give you a guaranteed quote at the time of service. We estimate your portion based on the most up-to-date

    information we have, but it is ONLY AN ESTIMATE. If you would like to know your insurance benefit, we will be happy to file a “pre-

    treatment estimate” with your insurance company prior to treatment. Keep in mind this is not a guarantee of coverage. This does delay

    treatment but will give you the best out of pocket figures you may require.

    ______ We will bill your insurance company as a courtesy. If insurance does not pay within 90 days, our office reserves the right to request

    payment in full for services from you and let you collect the insurance funds that are due to you. This is rare but it is important that you

    recognize that the insurance you have is a legal contract between YOU and your insurance company. Our office is not, and cannot be a part

    of that legal contract. Ulimately, you are responsible for all charges incurred in our office.

    ______ The office of George A. Davis, Jr., DDS FAGD does require payment in full for your portion at the time of service. We accept

    cash, MasterCard, Visa, American Express, Discover, aned checks (for existing patients with established payment history, picture ID will

    also be required). Credit card payments will only be charged if the card holder is present. We also offer payment plan options through two

    separate outside finance companies. Please ask for more information if you are interested in making payments. If unforeseen circumstances

    arise and there is a balance on your account that is held longer than 60 days your account will be charged interested at the contractual rate of

    two percent (2%), per month. If payment is not received on your balance, and your account is referred to our collection agency and/or their

    attorney, you agree to hereby agree to pay all “Costs of Collection.” Cost of Collection will be assessed up to an amount equal to the

    delinquent balance due. In addition to Collection Fees, all fees for accounts which must be forwarded or receive “Legal Action” will be added

    to the amount due. These fees will include: Attorney Fees, Court Costs, Service Fees, Levy and Lien Fees, which may be incurred.

    ______There will be a $50 processing fee for all returned checks. We do not accept post-dated checks.

    ______ A specific amount of time is reserved especially for you and we strongly encourage all patients to keep their appointments. If we do

    not receive notice at least 48 hours in advance, you will be subject to a $50 missed appointment fee per hour of scheduled appointment

    time. (Cancellations through SMS Text or Email are not preferred).

    ______ In the event of an emergency after regular business hours, a $175 emergency fee will be charged in addition to the necessary

    treatment fees.

    I read, understand, and agree to the provisions of the above conditions.


    Printed name of patient or person financially responsible

    X_______________________________________________ ________________________

    Signature of patient or person financiall responsbible Date

    mailto:[email protected]

  • 1930 Village Center Circle Suite #12 Las Vegas, NV 89134

    Phone - (702) 562-2322 Fax – (702) 562-9610

    Email – [email protected]

    Insurance Release – Authorization Form

    We are pleased that you have insurance, and will gladly assist you in whatever way possible to

    receive the maximum benefits available in your plan for any treatment you may incur in our

    office. However, please be advised that the contract is between you, your employer, and your

    insurance company. We are not a party to that contract.

    As a courtesy to you, we will do our best to receive the most up to date benefits from your

    insurance carrier. Based on the information we receive, we will estimate your out of pocket

    investment. However, in no way should this estimate be considered a guarantee of payment.

    Actual benefits will be determined by your insurance company when your claims are processed

    by them. At times throughout the year you will be made aware of any changes to your benefit

    plan, carrier, and/or coverage by your employer. We ask that you make us aware of these

    changes as soon as you are notified so we may update your file immediately.

    Authorizations: (Please sign both highlighted areas)

    I agree to be responsible for all charges for dental services and materials not paid by my dental

    benefit plan, unless prohibited by law. To the extent permitted by law, I consent to your use and

    disclosure of my protected health information to carry out any payment activities in connection

    with my claims.


    Patient/Guardian Signature Date

    I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to

    George A. Davis, Jr., DDS LTD PC.


    Patient/Guardian Signature Date

    mailto:[email protected]

  • HIPAA Contact Disclosure

    I, _______________________ (DOB)_______________, give Dr. Davis and staff authorization to disclose my

    protected health information to the following family, friends and/or caregivers:

    Name: _________________________Relationship:____________Phone:_____________

    Name: _________________________Relationship:____________Phone:_____________

    Name: _________________________Relationship:____________Phone:_____________

    Name: _________________________Relationship:____________Phone:_____________

    In the event The Dentist of Summerlin may need to give you information regarding your dental appointment

    or account, may we…..(initial all that apply)

    ______Leave a detailed voice message on this phone, the # is _______________

    ______Call you on your cellular phone, the number is _______________

    ______Call you at work, the number is ________________

    ______Speak to you directly ONLY

    I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this

    authorization I must do so in writing and present my written revocation in the office.

    I understand that the revocation will not apply to information that has already been released in response to

    this authorization. I understand that the revocation will not apply to information shared in the process of

    treatment, payment, or healthcare operations as sighted in the Notice of Privacy Practices.

    I understand that authorizing the disclosure of this health information is voluntary. The Dentist of Summerlin

    will not condition treatment, payment, enrollment or eligibility for benefits on providing or refusing to provide

    this authorization. I understand that any disclosure of information carries with it the potential for an

    unauthorized re-disclosure and the information may not be protected by Federal Confidentiality Rules. If I

    have questions about the disclosure of my health information, I can refer to my Notice of Privacy Practices,

    which I obtained from my dental office.

    Unless otherwise revoked, this authorization will expire on the following date, event or condition:

    ________________________________________________If I fail to specify a date this authorization will

    expire one (1) year from the signature on this form.

    ____________________________________ Date _______________________

    Signature of Patient

    ____________________________________ Date _______________________

    Signature of Guardian or Personal Representative

    ____________________________________ Date _______________________

    Signature of The Dentist of Summerlin Employee