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Patient Registration
History Information

Patient Registration

PERSONAL INFORMATION

 

DENTAL INSURANCE INFORMATION

 

Authorization

  • I authorize that as long as the office of Aledo Dental Associates, PA keeps this document on file, the office may use it to represent my consent for filing insurance claims. Unless restricted by my insurance policy, payment of insurance benefits, otherwise payable to me, will be made directly to Aledo Dental Associates, PA. I authorize release of information relating to these claims.

    I authorize my dental insurance company to release benefit and/or claim information to Aledo Dental Associates, PA.

    This will serve as my consent for general treatment. This consent is effective until such date as I cancel this consent in writing. My signature below signifies that I have read and understand this authorization.
 

History Information

DENTAL HISTORY INFORMATION

 

MEDICAL HISTORY INFORMATION

 

FINANCIAL ARRANGEMENTS

  • Welcome to our practice,

    From the moment you walk through our door you will notice that our goal is to make you feel at home in out pleasant, relaxed atmosphere. Our friendly staff will take special care to make certain that you are comfortable and well cared for.

    We provide advanced dental care, and haves dedicated our practice to excellence in painless dentistry. Your dental health is of the utmost importance to us. We will educate and counsel you on all procedures that you may require. Our staff is prepared to help train our patients in preventive dental care and proper hygiene.

    We look forward to a long term professional relationship with people such as you; to this end we have prepared the following so that you know what is expected of you, and we welcome you to our practice.

    Payment Responsibilities:
    Payment is due at the time services are rendered, unless payment arrangements have been approved in advance. For your convenience we accept MasterCard, Visa, Discover, American Express & Care Credit. Returned checks and balances older than 30 days will be subject to additional collection fees and interest charges. Charges may also be assessed for repeated missed appointments without a 24 hour advanced notice.

    Insurance Policy:
    We will file with your insurance company, but all patient portions are due at the time of service. Patient portions are calculated based on information we receive from your insurance company.

    However, your insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract. Our fees are generally considered within the acceptable range by most companies and therefore are covered up to the maximum allowance determined by each carrier. Not all services, however, are a covered benefit in all contracts.

    We must emphasize that as dental care providers our relationship is with you- not your insurance company. All charges are you responsibility from the date the services are rendered.

    I have read and understood the above financial policy.
 

ACKNOWLEDGE OF PRIVACY PRACTICES-HIPAA

  • The Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will beused to:

    Provide & coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly.

    Obtain payment from third-party payers for my health services.Conduct normal health care operations such as quality assessment and improvement activities.

    I have been informed of my dental provider’s Notice of Privacy Practices contain a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices.

    At times we will need to contact you concerning information that is specific to you, your treatment and your dental needs. Information that is requested to be sent to you, or on your behalf, by our office via email will be sent in standard email format. We do not have encrypted services available for such communication. We may have the need to use the telephone for confirmation of appointments or verification of health/dental needs. We will remain mindful all HIPAA laws concerning release of information in these instances.

    I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations and I understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
 
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