PATIENT REGISTRATION FORM: PLEASE ANSWER ALL QUESTIONS

Date:

Patient First Name

Patient Last Name

Patient Middle Initial

Patient Preferred Name

Date of Birth

Mailing AddressApartment/Suite

City/State/Zip Code

Email Address

Social Security #

Sex:
F M

Home Phone

Cell Phone

Employer

Marital Status

Spouse Name

Referring Dentist

Emergency Contact (not in household)

Emergency Contact phone #

Parent or Guardian Name (If Patient is a minor)

DENTAL INSURANCE INFORMATION

Please use your most current insurance ID card to complete the following fields.

Primary Insurance

Insurance Company

Subscriber ID #

Insurance Group #

Insurance Phone #

Insurance Address

City/State/Zip

Name of Policy Holder

Policy Holder Date of Birth

Policy Holder Social Security #

Relationship to Patient

Policy Type: Through employer Individual policy

Do you have secondary Insurance? Yes No

Secondary Insurance

Insurance Company

Subscriber ID #

Insurance Group #

Insurance Phone #

Insurance Address

City/State/Zip

Name of Policy Holder

Policy Holder Date of Birth

Policy Holder Social Security #

Parent or Guardian Name (If Patient is a minor)

MEDICAL HISTORY

Your preferred pharmacy name and address:

Your preferred pharmacy phone number:

Primary Care Doctor:

Primary Care Doc. City & State

PAST MEDICAL HISTORY

Select YES or NO if you currently have any of the following conditions
NO known past medical history

IF YES TO ANY OF THE ABOVE, PLEASE EXPLAIN:

**FOR FEMALE PATIENTS**

Are you pregnant? Yes No

How many weeks?

Name of OB/GYN Doctor

Nursing? Yes No

MEDICATIONS

NO known medications

Name

Strength

Name

Strength

Name

Strength

Name

Strength

Name

Strength

ALLERGIES

NO known allergies

Latex allergy

Penicillin allergy

Please list any additional medication allergies:

HIPAA PRIVACY FORM

PATIENT RECORD OF DISCLOSURES

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual's home.

I wish to be contacted in the following manner (Check all that apply):

Cell phone:

O.K. to leave message w/ detailed info Leave message w/ call back number only

Home phone:

O.K. to leave message w/ detailed info Leave message w/ call back number only

Work phone

O.K. to leave message w/ detailed info Leave message w/ call back number only

I allow Endodontics of the Triad to discuss my medical information with:

Name

Relationship

Name

Relationship

I request that my medical information NOT be shared with anyone other than another medical provider or a pharmacy.

The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use or disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to the uses or disclosures made pursuant to an authorization requested by an individual.

Note: Uses and disclosures for TPO may be permitted without prior consent in an emergency.

Acknowledgement of receipt of the Notice of Privacy Practices (HIPAA)

I, the undersigned, have received a copy of, and been given the opportunity to ask any questions I may have regarding this Notice.

Signature of patient (parent or legal guardian if minor)

Date

Name

First Name

Last Name

Signature of Authorized Person

FINANCIAL POLICY

Please note that payments are expected at the time of service, including estimated co-payments, unmet deductibles, and any non-covered charges from your insurance company. For patients without insurance coverage, payment in full is expected at the time of your visit. For patients with insurance coverage, we ask that you pay in full for your examination fee and we will file with your insurance for reimbursement. If endodontic treatment is rendered, we will file your insurance and only collect the estimated co-payment you will owe for treatment as a courtesy at the time of service. While we strive to obtain the most accurate information on insurance benefits and coverages for each patient, please remember that insurance is a contract between the patient and the insurance company. If you have any questions regarding your dental benefits, please contact your employer or insurance company directly. We work with many different insurance companies, and it is not possible to give you a guaranteed quote at the time of service, it is only an estimate. Discrepancies may arise between the estimated coverage and the actual coverage when claims are processed by your insurance provider, and in the event of any discrepancies, you will be responsible for any remaining balances owed to Endodontics of the Triad. Although this is rare, if your insurance does not pay within 90 days, we reserve the right to request payment in full for services from you and let you collect the insurance funds that are due to you. If your insurance pays us and there is a refund owed to you, we will make every effort to process it within 30 days.

When emergency treatment is rendered after business hours or on weekends, we require full payment at the time of service as well as an after hours fee. If you have dental insurance we will file it on the next business day and any reimbursement will be sent directly to you.

We accept most dental insurances as out of network providers, including PPO plans from Aetna, Ameritas, Cigna, Guardian, Humana, Lincoln, Metlife, Principal, Sunlife, UnitedHealthcare (UHC) and more. We accept Delta Dental and Blue Cross Blue Shield, but the reimbursements from your insurance plan will be sent directly to you; therefore we require that you pay in full for treatment at the time of service. We do not accept Medicare, NC Health Choice, HMOs, DMOs, or any other plans that limit your options to a specific group of providers.

Our office requires payment in full of your estimated portion at the time of service. We accept Visa, MasterCard, Discover, American Express, cash and checks. If you are in need of an extended finance option, we also work with CareCredit and Cherry.

I hereby authorize and direct my insurance carrier to issue payment directly to Endodontics of the Triad for services rendered to me and/or my dependents. I have read the Financial Policy and understand that I am responsible for any amount not covered by my insurance.

YES, I AGREE to the Financial Policy and Assignment of Insurance Benefits

SCHEDULING & CANCELLATION POLICY

We will schedule your appointment as promptly as possible. If you have pain or an emergency situation, every attempt will be made to see you the same day. Dr. Applebaum is available on her cell phone for true emergencies at 336-255-9593.

We ask that you give us 24 hours notice if you will not be able to attend your appointment so we can schedule another patient in that time slot. Patients arriving more than 15 minutes late may be required to reschedule their appointment. We try our best to stay on schedule to minimize your waiting. Various circumstances may lengthen the time allocated for a procedure and emergency cases can also arise and cause delays. We appreciate your understanding and patience.