Hillview Family Dentistry

 

Hillview Family Dentistry

 

 

Today’s Date: ____________________

Patient’s Name:______________________________________________________ D.O.B. _________________

Home Address: ______________________________________________________________________________

City: _______________________________  State:  _______________________ Zip: ______________________

Employer: ___________________________  Work Number: ______________________________________

E – Mail address: _____________________________________________________________________________

Home Phone Number: ___________________________  Cell Number: ___________________________

Social Security Number: _____________________________

Person Responsible for account: ___________________________________________________________

Driver License Number: _____________________________

How did you hear of our office? ____________________________________________________________

Dental Insurance:  Y    N    Insured Name: _________________________________________________

Insured’s Social Number:  ______________________ D.O.B. ___________________________________

Insurance Company: ________________________________________________________________________

Insurance Company Address: ______________________________________________________________

Insured Employer: _____________________________ Phone  Number: _________________________

ID Number: _______________________________   Group Number: ______________________________

Secondary Insurance:  Y  N   Insured Name: _____________________________________________

Insured’s Social Number _________________________ D.O.B. _________________________________

Insurance Company: ______________________________________________________________________

Insurance Company Address: ____________________________________________________________

Insured Employer: _____________________________ Phone Number:  _______________________

ID Number: _______________________________  Group Number: _____________________________

 

 

Hillview Family Dentistry

Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations. (HIPPA)

 

I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment.  I understand that this information serves as:

 

• a basis for planning my care and treatment

• a means of communication among the many health professionals who contribute to my care.

• a source of information for applying my diagnosis and surgical information to my bill

• a means by which a third-party payer can verify that services billed were actually provided.

• and a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals

 

I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures.  I understand that I have the right to review the notice prior to signing this consent.  I understand that the organization reserves the right to change their notice and practices and prior to implementation will mail a copy of any revised notice to the address I’ve provided. I understand that I have the right to object to the use of my health information for directory purposes.  I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon.

 

I request the following restrictions to the use or disclosure of my health information.

 

 

 

Accepted _________________  Denied __________________

 

Signature of Patient or Legal Representative: _________________________________________

 

Today’s Date: ____________________________

 

 

Hillview Family Dentistry

119 Topfield Rd Louisville, KY 40229

Office Policy

 

Thank you for choosing us as your dental health provider. We are committed to your successful treatment. Please understand that payment of your bill is considered a part of your treatment. In order to keep our fees from rising dramatically and to minimized the expenses of billing and bookkeeping, the following financial policy will be in effect at our office:

 

All patients must complete our patient information form and insurance form before seeing the doctor.

 

• Estimated portion of payment is due at the time of service.

• We accept cash, checks, debit cards, Visa, Master Card, and Discover

 

Dental insurance does not cover 100% of the cost of your treatment.  Because of this and the extreme delay in receiving payment from many insurance companies, you will be asked to pay your deductible and your Estimated portion on the day services are rendered.  We will Estimate as closely as possible your coverage, but until we actually receive the insurance payment, it is only an Estimate. We will assist you in dealing with your insurance company, but ultimate responsibility lies with you.  Your insurance is a contract between you and the insurance company.  After 90 days your account balance is due in full even if you’re insurance has not yet paid. If the account is not paid within the 120 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and other expenses incurred in the collection of your account.

 

Late Payment Charges: If you minimum payment is not received by the due date, you may be assessed a late payment charge.  The amount of the late payment charge to be assessed is the maximum amount authorized under the laws of the state of your domicile.  IN most states, the late charge will be $5.00 or 5% of the past due minimum payment, which ever is great, with maximum of $20.00.

 

Finance Charge:   A finances charge is imposed on those charges not paid in full within 90 days of the date you were first billed for the charges.  The finance charge is periodic rate of .66% per month with an annual rate of 8%.  The finance charge is computed by multiplying the balance on which the finance charge is computed by the periodic rate shown above.  There is a $1.00 minimum finance charge.

 

If you think that you have been incorrectly, or if you need more information about a transaction on your bill, please call the office and we will be happy to assist your.  Every effort will be made to make suitable arrangements for payment but if the account fails to be paid and there are no arrangements made, after 120 days the account may be turned over to our attorneys and all collections fees will be billed to you the patient.

 

                                                                                                                     Initial ______

Office Policies cont. 

 

 

In order to provide you with the best care possible, there are some guidelines we follow to keep the office running smoothly.

 

• Office visits are by appointment only, if you have and emergency, please call and we will work you in as soon as possible.  Patients with appointments hold priority unless the emergency is serious.  Therefore, there may be a wit if you are worked in.  We appreciate your understanding and cooperation on this matter.

 

• If you can not make your scheduled appointment, it is necessary to inform the office 24-hours in advance.  We will be more than happy to reschedule your appointment at to a more convenient time for you.  On your first missed appointment occurrence you will receive a warning letter.  On you second missed appointment you will receive a $25.00 failed appointment charge to your account.  After the third missed appointment, without 24-hour notice, the doctor reserves the right to dismiss you as a patient.

 

We strongly urge you to keep scheduled appointments especially if you are in the middle of treatment.  We are usually booked 3-4 weeks in advance so any rescheduling will result in a delay in finishing you case.  We do understand that emergencies happen and we will take that into consideration.

 

 

Authorization and Release

 

I authorize the dentist to release any information including the diagnosis and the records of any treatment of examination rendered during the period of such dental care to third party payers and health practitioner.  I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me.  I understand that my dental insurance carrier may pay less than the actual bill for service.  I agree to be responsible for the payment of all services rendered on my behalf of my dependents.

 

 

 

__________________________________                                                __________________

Signature                                                                                                Date

 

 

 

Hillview Family Dentistry

119 Topfield Rd. Louisville, KY 40229

502-957-4408

Dental Consent Form

 

 

I hereby authorize and direct the dentist of Hillview Family Dentistry to perform the following dental treatment or oral surgery procedures, including the use of any necessary or advisable local anesthesia, radiographs or diagnostic aids:

 

• Consult with examination for future treatment.

• Preventive hygiene treatment, (Prophylaxis) and the application of tropical fluoride.

• Application of plastic “sealants” to the grooves of the teeth

• Treatment of diseased or injured teeth with restorations(fillings and crowns).

• Replacement of missing teeth with dental prostheses (bridges, partials and dentures)

• Removal (extraction) of one or more teeth.

• Treatment of diseased or injured oral tissue (hard and/or soft)

 

I understand there are risks involved in this treatment and hereby acknowledge that these risks will be explained to me. I will have the opportunity to ask questions regarding the treatment and the risks and that I dully understand the same.

 

I will be advised that the success of the dental treatment to be provided will require the patient or parents of the patient to follow post-care instructions. I agree that the success of the treatment requires that all post-operative and post – care instructions be followed and regular office visits as scheduled must be maintained.

 

I realized that during the course of treatment unforeseen circumstances may necessitate additional or different procedures from those discussed. I therefore authorize and request the performances of any additional procedures that are deemed necessary for desirable oral health and well being, in the judgment of the treating dentist.

 

There are possible risks and complications associated with the administration of local anesthesia, sedation and drugs. The most common of these are swelling, bleeding, pain, nausea, vomiting, bruising, tingling, numbness of the lips, gums, face and tongue, allergic reactions, hematoma, (swelling or bleeding at the injection site), fainting, lip or cheek biting resulting in ulceration and infection of the mucosa.  I also understand that there are rare potential risks such as unfavorable reactions to medications in the respiratory and cardiovascular collapse (stopping of breathing or heart function) and lack of oxygen to the brain that could result in coma or death.  I understand and have been informed o the above risk and complications.

 

I agree to the use of local anesthesia and the use of nitrous oxide/oxygen analgesia depending on the judgment of the dentist. Nitrous oxide/oxygen may produce nausea and vomiting. I am also aware that the nosepiece leaves an indentation or ring around the nose, which disappears shortly afterwards.   I understand and have been informed of the above risks and complications.

 

I hereby state that I have read and understand this consent and that all questions about the procedures will be answered in a satisfactory manner and that I have the right to be provided answers to questions which may arise during and after the course of my treatment.

 

I also understand that this consent will remain in effect until such time that I choose to terminate it.

 

Patient’s Name _________________________________________________________________________

 

Name of Parent or Guardian_______________________________________________________________

 

Signature of Patient or Parent/Guardian______________________________________________________

 

 

 

Hillview Family Dentistry

119 Topfield Rd

Louisville, KY 40229

502-957-4408

Dental History

 

Any sensitivity? (Y/N) ________ (Hot, Cold, Sweet)

Where? UL, UR, LL, LR

Headaches, earaches, neck pain, jaw joint pain? (Y/N) ________

Teeth or fillings breaking? (Y/N) __________

Grinding or clenching teeth? (Y/N)  _______

Bleeding, swollen or irritated gums?  (Y/N) _________

Loose, Tipped or shifting teeth?  (Y/N) ________

Bad Breath? (Y/N) ________

Do you have, or have you had any of the following? (Y/N) ________

Denture, Partial dentures, Braces, Periodontal (gum) disease?

 

Your last cleaning? ________________________________

Your last oral cancer screening? ______________________

 

Do you smoke or use chewing tobacco? (Y/N) ________

How much? ___________  How Long? __________

If I could change my smile, I would: (circle)

Make them whiter

Make them straighter

Close Spaces

Replace black metal fillings with tooth colored restorations

Replace old crowns that don’t match

 

Your previous Dentist? __________________________

City:____________________  State: ______________________

 

On a scale of 1-10 10 being the highest rating:

 

How important is your dental health to you? __________________

 

Where would you rate your current dental health? _____________

 

Where do you want your dental health to be? _________________

 

Why did you leave your previous dentist? _______________________________

 

_________________________________________________________________

 

What is the most important thing to you about your future smile and dental health?

___________________________________________________________________

What is the most important thing to you about you dental visit today?

____________________________________________________________________

 

Hillview Family Dentistry

119 Topfield Rd.

Louisville, KY 40229

502-957-4408

 

Health History

 

What medications are you currently taking? ______________________________________________________________________________________

 

______________________________________________________________________________________

If female are you taking birth control pills? (Y/N) ________

Are you pregnant? (Y/N) ________

Are you nursing? (Y/N) ________

 

Please circle any conditions that pertain to your health.

Any questions please ask front desk or dentist.

 

 

 

Abnormal Bleeding  

Allergies

Heart Attack

Angina Pectoris

Hepatitis A

Hepatitis B

HIV + AIDS

Liver Disease

Diabetes

Pneumocystitis

Emphysema

Fainting Spells

Frequent Headaches

Glaucoma

Hay Fever

Tuberculosis

Hemophilia

Yellow Jaundice

Asthma

Cancer/Chemo

Cosmetic Surgery

Mitral Valve Prolapse

Psychiatric Problems

Rheumatic Fever

Shingles

Sinus Problems

Alcohol abuse

Thyroid Problems

Heart Surgery

Venereal Disease

Artificial Bones

High Blood Pressure

Kidney Problems

Low Blood Pressure

Difficulty Breathing

Drug Abuse

Epilepsy

Fever Blisters

Stroke

Anemia

Ulcers

Arthritis

Artificial Heart Valve

Blood Transfusion

Colitis

Congenital Heart Defect

Pace Maker

Radiation Therapy

Seizures

Sickle Cell Disease

 

Explain any other condition if not listed: ____________________________________________

 

______________________________________________________________________________

 

Allergies: Aspirin   Codeine   Erythromycin    Jewelry   Latex   Metals   Penicillin    Tetracycline: 

Others: ______________________________________________