UEDI Patient Form First Name Last Name Which gender do you identify with ? Male Female Other Address City State Choose... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho IllinoisIllinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Montana Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Telephone (Home) Telephone (Work) Telephone (Cell) Email address Marital Status : Single Married Divorced Widowed Other Date of Birth Age S.S.# Company Name & Address Occupation Preferred Appointment Days Time Referred By In Case of emergency, Contact Telephone Name of last Dentist Telephone Date of last dental examination Date of last series of full mouth X-Rays Are you in good health? Yes No Has there been any change in your general health within the past five years? Yes No Do your gums bleed when you brush? Yes No Are you happy with your Smile? Yes No Do you smoke cigarettes, cigars, or pipes? Yes No Are you interested in whitening your teeth? Yes No Do you have any problem eating certain foods? Yes No Do you have sensitivity to hot or cold foods? Yes No Have you ever been Pre-Medicated with antibiotics before any dental treatment? Yes No Have you had orthodontics? Yes No If yes, how many years? At what age? List ALL hospitalizations and serious illnesses Date Do you have or ever had any of the following : Diabetes? Tuberculosis? Swollen Ankles? Thyroid Problems? Psychiatric treatment? High Blood Pressure? Recent increase in thirst? Arthritis or rheumatism? AIDS, ARC, HIV infection? Prosthetic or Artificial joint? Recent increase in urination? Prosthetic or Artificial heart valve? Kidney trouble or Renal Dialysis? Irregular heartbeat or pacemaker? Stroke, seizures, or convulsions? Hepatitis, liver disease, or jaundice? Hearing problem or vision problems? Persistent cough or coughing up blood? Venereal disease? Syphilis? Gonorrhea? Enlarged lymph nodes or swollen glands? Stomach ulcers or stomach problems? Shortness of breathes after mild exercise? Asthma, emphysema, or difficulty breathing? Heart attack, angina, or other heart disease? Diagnosed with a Heart Murmur/Mitral Valve? Autoimmune disease or lupus erythematosus? Rheumatic Fever or Rheumatic Heart Disease? Cancer, radiation treatment, or chemotherapy? Blood disorder, bleeding tendency or frequent bruising? Do you have any allergies? Yes No If yes, What ? Have you ever taken penicillin? Yes No Have you ever had a bad reaction to any drug or medication? Yes No What type of drug or medication? Penicillin or other antibiotic Aspirin Dental anesthetic Codeine or other narcotics Other [WOMEN ONLY] Are you pregnant? Yes No List all the drugs or medications you are currently taking Name of Medication Dosage How Long Reason Are you under the care of a physician ? Yes No Please provide the MD’s name, address and phone number : Name Phone Number Address In addition to those you have listed, have you taken any of the following medications or drugs within the past year? If yes, please check the appropriate box. Medication for asthma Medication for anxiety (nerves) Medication for depression Medication for stomach ulcers Medication for a heart problem Anticoagulants (blood thinners) Insulin or pills for diabetes AZT/other drugs for HIV infection Cancer, Chemotherapy Methadone maintenance Cortisone/other steroids Medication for high blood pressure Nitroglycerin/Medication for angina/chest Aspirin, arthritis/pain medication Other : Pharmacy Name Pharmacy Phone Number I will assume responsibility of notifying Dr. Harvey and Associates of any changes in my medical history or contact information. Patient/Guardian Signature Date PERSONAL DENTAL NEEDS SURVEY Would you like to have Nitrous Sedation for your dental treatment (s) Yes No Please rate on a scale of 1-5 the importance of each of the following regarding your dental care.(The most important would be #1). Preventive dental health care Freedom from pain Excellence and quality of service Cost and Affordability Other Please rate, as above, what a dentist must do to gain your confidence Show me what he/she is doing or needs to do so I can clearly understand what is happening. Listen to my concerns and explain thoroughly the procedures to be performed. Make sure I feel comfortable and informed always. Please choose the level of fear you have about dental visits (10 being the highest) 1 2 3 4 5 6 7 8 9 10 I would like to know about these options available to me for maximizing my comfort and my experience during my visit.(Check all that apply) Music and earphones Sedative medications Nitrous Oxide Patient education materials Are you concerned about the following? (Check all that apply) Existing discomfort? Prevention of decay? Whitening your teeth? Mouth odor? Replacing old silver fillings? Appearance of my smile? Recurring or untreated gum disease? Other : How many times do you wake-up at night? Do you sleep on your stomach back sides When discussing my treatment plan, I prefer : THE BIG PICTURE DETAIL BY DETAIL When evaluating my smile, it’s most important : WHAT I SEE WHAT OTHERS SEE What would make you choose our dental office over another? DENTAL INSURANCE Primary Dental Insurance Employer name Group# Employer Tel# Ins. Co. Name Insurance Tel# Subscriber Name Subscriber Date of Birth SSN/ID/Contract# Relationship to patient : Self Spouse Parent Other Secondary Insurance/Medical Insurance Employer Name Group# Employer Tel# Subscriber Name Insurance Company Name Subscriber Date of Birth Insurance Tel# SSN/ID/Contract# INSURANCE AUTHORIZATION I Certify that I, and/or my dependent(s), have insurance coverage with Your Name and assign directly to Upper East Dental Innovations PLLC all insurance benefits, if any, otherwise payable to me for services rendered. I authorize any holder of medical or other information about me to release to such payer or their agents any information needed to determine these benefits for related services. I understand that I am financially responsible for all charges whether paid by insurance. I authorize the use of my signature on all insurance submissions. I hereby authorize Upper East Dental Innovations PLLC, to furnish insurance companies or their representatives information concerning my (my dependents) illness and treatments and I hereby assign to Upper East Dental Innovations PLLC all payments for medical/Dental services rendered by myself or my dependents. The above-named dentist may use my health care information and may disclose such information to the above-named insurance company (is) and their agents for obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. Signature of Patient, Parent, Guardian or personal Representative HIPAA Patient Consent Form The federal government requireds all medical offices to make patients aware that they have rights regarding the use of their personal health information. Our notice of privacy practices is available for your review at the front desk. By signing this form, you consent to our use and disclosure of protected health information per the Notice of Privacy Practices available to you at our front desk. I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out: Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment). Obtaining payment from third party payers (E.G. my insurance company) The day to day healthcare operations of your practice. I have also been informed of, and given the rights to review and secure a copy of your Notice of Privacy Practices which contains a more complete description of the use and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these request restrictions. However, if you do agree, you are bound to comply with this restriction. I understand that I may revoke this consent at any time, in writing, signed by you. The Patient understands that: We will not release information to any future doctor, attorney, life insurance company, or workman’s company without your written consent. Protected health information may be used for treatment through one of your current doctors (such as your primary care physician or a specialist referral), payment with your insurance company, or healthcare operations within our office. The practice of Upper East Dental Innovations PLLC reserves the right to change the notice of privacy practices. The patient has the right to restrict the use of their information, but the practice of Upper East Dental Innovations PLLC does not have to agree to these restrictions if, for example, it interferes with payment, daily operations, or providing quality health care The patient may revoke this consent in writing at any time and all future disclosures will then cease The practice Upper East Dental Innovations PLLC C may condition treatment upon the execution of this consent (for example, you may be required to pay your visit at the time of service) Signature Relationship to Patient Understanding Dental Benefits Note we do not accept nor participate with any DMO/HMO/Union Plans /Medicaid /Discount Plans, Dr. Harvey participates in most PPO insurance plans, and ALL our Specialists and Associates are OUT OF NETWORK. Most plans have a yearly maximum dollar amount that they will reimburse. After you have reached your limit, you will be responsible for full payment. Your Annual Maximum for the year is We will bill your dental benefits provider, (usually an insurance company), for services performed at. Though we verify your benefits with your benefits provider, it is not a guarantee of payment and may vary when the actual claim is submitted and processed by your insurance company. As a first-time patient of Upper East Dental Innovations, your first visit you will consist of a Comprehensive Exam, Full Mouth Series of X-rays, Dental Cleaning, Intra Oral Photos, Oral Cancer Screen, Oral Hygiene Instructions, and Fluoride. You will be required to come in at least twice a year for your dental check-up and cleaning. This preserves your dental work we cannot guarantee our work should you choose not come in for regular 6 month recall dental care. Your 6-month appointment will be automatically generated by our scheduling system at the end of every preventative visit. This will assure you have a consistence dental check-up and cleaning as recommended by the ADA. Our goal is to help you maximize your dental benefits. We are not responsible for circumstances beyond our control, such as: Waiting Periods, Frequency, Limitations Yearly Maximums, Missing Tooth Clause, Fee Schedules Downgrades, etc. Regardless of coverage, your estimated co-pay is due in full the day of treatment. The exact payment from your benefits provider may vary so you may receive a bill after we receive a payment from your dental benefits provider (this may take 2 – 6 weeks after treatment). I understand and authorize Upper East Dental Innovations PLLC to take all diagnostic materials needed to make a final diagnosis of dental treatment. Diagnostic materials may include Intra-oral pictures, radiographs, digital radiographs, diagnostic models, photographs and slides. This material may be used for lectures, articles and or publications. I authorize Upper East Dental Innovations PLLC to perform and or administer all forms of treatment, medication and anesthesia that may be necessary. I understand I can obtain this practice’s current Notice of Privacy Practices on request. I hereby acknowledge that I have been provided with a copy of the Notice of Privacy Practices. Patient/Guardian Signature PLEASE NOTE THE PAYMENT AND CANCELLATION POLICY OF OUR OFFICE Payments are due the day of service. Payments for services can be made by THREE WAYS: 1. Visa, MasterCard 2. Cash, in advance for the entire treatment plan, in full (which you will get 5% off) And 3. Monthly payment plan. Should you have any questions about this, please let us know. I understand that the dental treatment presented to me is my financial responsibility and that all fees for services are due and payable up front as authorized by Upper East Dental Innovations PLLC and or administrator. APPOINTMENTS When you make your appointment, it is confirmed. To keep our schedule timely and can accommodate all our patients efficiently we ask that you provide 48 hours advanced notice should you need to cancel an appointment. This time has been reserved for you; we schedule appointments so that we never must rush. We do not over schedule. A $100.00 fee will be charged for appointment cancelled less than 48 hours. Account balances are due within 7 days of receipt of a bill. We reserve the right to charge 12% APR for accounts not paid after 14 days. Thank you for your kind cooperation. REQUEST FOR X-RAYS X-rays must be requested in writing and will release directly to the patient. A $25.00 administrative fee will be charged for a copy of X-rays/ Records CONSENT FOR INTERNET COMMUNICATIONS I give consent to Upper East Dental Innovations PLLC to electronically send x-rays, medical records, and other information pertaining to my patient care at Upper East Dental Innovations PLLC. Patient/Guardian Signature If you have any questions or concerns about our office or our policies, please do not hesitate to discuss them with us.We want you to have the best dental care in the most pleasant environment. Your concerns are, therefore, our concerns. Submit
