The Dentist of Summerlin...The Dentist of Summerlin Patient Information George A. Davis Jr., D.D.S....
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___________________
HAVE EVER HAD ANY SERIOUS ILLNESS NOT LISTED ABOVE? YES NO
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
HAVEHAVE
HAVE
HADHAD
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CHECK ALL THAT APPLY: FAMILY HISTORY UNKNOWN? YES NO
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.
X_______________________________________________
Printed name of patient or person financially responsible
X_______________________________________________ ________________________
Signature of patient or person financiall responsbible Date
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.
X____________________________________________________________________________
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.
X____________________________________________________________________________
Patient/Guardian Signature Date
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