Cloud 9 Health History/HIPAA/Communication Authorization/Media Consent - Buda Header Image

PATIENT INFORMATION

:  
What helped you decide to come to our practice?
The following information is for a(n):*
Gender:*
Patient's Date of Birth*
Is texting permitted?*
Home Address:
Parents' Marital Status:
Marital Status:
Person Responsible for Account:

HIPAA Consent

This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask for our Privacy Consent Person or direct your questions to this person at our office address.*

Authorization for Cell Phone and Email Use

I give my consent to the provider to use my cell phone for appointments, treatment information, insurance, account and billing information and special promotions. I understand that I can withdraw my consent at any time.

Choose all that apply:*
Certification:*

Photographic / Media / Social Media Consent

  • Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to the provider and its affiliates and agents, to use my image, video and photographic likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet and Social Media sites).
  • I hereby consent to the collection and use of my personal images by photography or video recording.
  • I further acknowledge that the provider may use my image in media to promote the practice in the future.
  • I understand that no personal information, such as names, will be used in any publications unless express consent is given.
  • I also understand that my consent can be withdrawn at anytime in writing to the provider.
I have read the above statements and I give this consent voluntarily.*

Financial Policy Consent Form

We are committed to providing you with the best possible dental care. Our fees reflect our professional commitment to excellence. In order to achieve these goals, we need your assistance and understanding of our payment and financial policy. We offer the following methods of payment:

  • Payment in full is due at the time of service. Cash, Check, Debit Card, MasterCard, Visa, Discover and American Express accepted.
  • Payment in full is due at the time of service unless other arrangements have been made
  • For patients with insurance, we will accept payment directly from the insurance company, but require that the deductible and non-covered fees be paid at each visit.
  • Any parent/guardian bringing a child to our office is legally responsible for payment of all services rendered. We do not bill individual parents for child’s co–payment.

Important Information Regarding Your Dental Benefits

  • Your dental benefit program is a contract between you, your employer, and the insurance company. We are not a party to that contract. This office files your insurance as a courtesy to you.
  • Not all dental services are a covered benefit in all contracts. It is your responsibility to know your benefits.
  • You (not the insurance company) are responsible to us for all our fees for services rendered to you.
  • An ESTIMATE will be given of the benefits that the insurance company is expected to pay. Remember that this is only an ESTIMATE and that the actual cost may vary.
  • BROKEN/MISSED APPOINTMENT: Appointments reserve a specific time with the provider to perform and provide the care you need. These scheduled times are planned for you convenience and hold great value. We require 48-hour notice of canceling or rescheduling your appointment, if 48 hours’ notice is not given a fee may be charged to your account.
I acknowledge I have received and agreed to the provider's Payment & Financial Policies. *

New Patient Health Consent

Thank you for choosing our office as your dental healthcare provider. We are committed to providing you with the highest quality lifetime dental care, so that you may attain optimum oral health.

 

The following is a statement of our Financial Policy, which we require that you read, agree to and sign prior to any treatment.

 

Please note: Additional fees will be applied for returned checks. All account balances over 90 days are subject to a late fee.

Do you have insurance?

  • As a courtesy to you, we will help you process all of your dental insurance claims. Please understand that we will provide an insurance estimate to you; however, it is not a guarantee that your insurance will pay exactly as estimated. Insurance coverage is subject to limitations, exclusions, waiting periods, frequency, age restrictions, deductibles and maximums which are your responsibility. Please contact your insurance company for a detail of your benefits. Your insurance company and your plan benefits ultimately determine the amount paid. We will do all we can to ensure your estimate is as accurate as possible. Your estimated insurance benefit may differ due to a number of reasons, specifically related to your plan.
  • All charges you incur are your responsibility, regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you and your insurance company. Our office is not a party to that contract.
  • Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.
  • We ask that you sign this form and/or any other necessary documents that may be required by your insurance company. This form instructs your insurance company to make payment directly to our office. I authorize the release of any information concerning my (or my child’s) health care advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits.
  • We ask that you pay the deductible, co-payment and co-insurance, which is the estimated amount not covered by your insurance company, by cash, check, MasterCard, Visa, Discover, American Express and CareCredit at the time we provide the service to you.
  • Insurance payments are ordinarily received within 30-60 days from the time of filing a claim. If your insurance company has not made payment within 60 days, we will ask that you contact your insurance company to make sure payment is expected. If payment is not received or your claim is denied, you will be responsible for paying the full amount at that time.
  • We will cooperate fully with the regulations and requests of your insurance company that may assist in the claim being paid. Our office will not, however, enter into a dispute with your insurance company over any claim.

Minors accompanied by the parent or legal guardian: The parent or legal guardian accompanying a minor, who has consented to treatment are responsible for full payment at time of service unless other arrangements have been made.

Unaccompanied Minors: The parent or legal guardian is responsible for full payment at time of service. Treatment consents and payment arrangements with the parent or legal guardian must be made prior to appointment or non- emergency treatment may be denied.

Missed Appointment (s) and Cancellations:

Our goal is to provide treatment in a timely manner with as few visits as necessary.  We understand that unforeseen circumstances may arise, which may result in canceling or missing your appointment. A charge may be assessed for multiple missed, short notice or cancelled appointments. Multiple failed appointments may result in being dismissed from the dental practice.

Consent: I have read, understand and agree to the above terms and conditions. I authorize my insurance company to pay my dental benefits directly to my dental office. I understand that responsibility for payment for dental services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered.*

DENTAL INSURANCE

We welcome you and your family to our practice. We look forward to providing you with top-notch quality dental care at affordable prices. To provide you with the most beneficial and comprehensive service and care, we request you to review and complete our office and financial policy consent form. We will be happy to answer any questions you may have regarding the proposed treatment and available financial options. We strive to keep you informed and involved with your treatment as much as possible.

You need to be aware that:

  • We will always do our best to help you to maximize your benefits.
  • Although we file claims for you as a courtesy, your dental insurance policy is a contract between you, your employer and your insurance company. We are not a party to that contract.
  • Your treatment plan is individually tailored, and is not based on your dental insurance benefits or lack of benefits.
  • Not all services are covered benefits in all contracts. Some insurance companies arbitrarily select certain services they will not cover.
  • It is your responsibility to thoroughly understand the coverage and exceptions of your particular policy. Coverage issues can only be addressed by your employer or group plan administrator. We cannot act as a mediator with the carrier or your employer.
  • Our staff is trained to help you with questions you may have relating to how your claim was filed, or regarding any additional information your carrier may need to process your claim. Please, ask if you have any questions.
  • As a courtesy to all of our insured patients, we will file your dental insurance claim forms. In special circumstances, a particular insurance company's benefit check can be sent to our office directly. In such cases, you are responsible at the time of treatment for payment to us of any applicable deductible and for your co-insurance portion. Any payments made directly to you by your insurance company on unpaid balances should be forwarded immediately to our office so that your account may be credited accordingly.
  • Your claim will be filed immediately, and benefits are expected are to be paid within 30-45 days.

The filing of an insurance claim does not relieve you of timely payment on your account. If the claim is not cleared by your carrier in 60 days, the unpaid portion will automatically become "self-pay" and a statement will be issued to you for the unpaid portion. You are responsible for any amounts your insurance company chooses not to pay for whatever reason.

Please feel free to contact your insurance company regarding unpaid benefits. We will gladly provide you with a letter which would include all pertinent information which you may sign and mail. I understand and accept the financial and the dental insurance policies listed above and have had any and all questions answered to my satisfaction.

I agree to pay for all treatment in a timely fashion as described.


Refund Policy

All payments collected on date of service may be refunded same day.  Refunds Request after date of service will be processed within 15 days of refund submission form. Please note ALL PENDING INSURANCE CLAIMS must be paid by your insurance company before a refund may be made.


Do you have Dental Insurance?*

[For patients with dental insurance who would prefer their Ins. Company to send payment to the office?]

I hereby authorize my insurance benefits to be paid directly to the provider. I realize that I am responsible to pay for any deductible amount(s), my co-insurance portion and for any non-covered services. I understand that I am financially responsible for any and all charges of dental treatment and incurred fees, whether or not paid by said insurance and I agree to pay such charges in full. I also hereby authorize the release of pertinent medical/dental information to the insurance carrier(s). This order will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.*
Do you have Secondary Insurance?

PATIENT DENTAL HISTORY

Do you have a Dentist?*
Have there been any injuries to the face, mouth or teeth?*
Have you had or do you presently have any of the following habits?
Have you been informed of any missing or extra permanent teeth?*
Are you aware of sores, lumps or irritated areas in the mouth?*
Has an orthodontist been consulted previously?*
Have you had previous orthodontist treatment?*
Have you ever been treated for:*
Do you have bleeding gums?*
Are you concerned about the appearance of your teeth?*
Do you have any speech problems?*
Is there anything you would like to change about your smile?*
What aspect of dental treatment are you most concerned with?*

PATIENT MEDICAL HISTORY

Is your general health good at this time?*
Are you under the care of a physician at this time?*
Are you taking any medication?*
Do you have any allergies? (Penicillin, Sulfa, Latex, etc.)*
Have you ever had a serious illness or been hospitalized?*
Have you had your tonsils and/or adenoids removed?*
Have you ever been advised by your physician to take an antibiotic prior to any dental treatments?*
Do you have any special problems not listed?*
Do you use tobacco? (smoking or chewing)*
Have you recently noticed a growth spurt?*
Are you pregnant or considering pregnancy during the next 2 years?*
Are you currently taking medication for birth control?*
Are you nursing?*

DO YOU HAVE NOW, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING?

(Please select all that apply)

I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION. I grant authority to the Doctor and Staff to perform all procedures and treatments in my best interest. I authorize the provider to share treatment information with collaborating dentists and surgeons when appropriate. I authorize the provider to submit treatment information pertinent to this patient to the Insurance Company for billing purposes only. I understand that, when appropriate, Credit Bureau reports may be obtained.

Our practice may use your records for educational and promotional purposes. I know this is in the Consent form, but it allows us to use their photos, etc. for teaching purposes even if they do not start treatment.
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