Patient Information Form- NY Implant Dentistry

Insurance/Financial Agreement
Primary Dental Insurance
Does the patient have dental insurance?*

YesNo
Who is responsible for this account?*
Relationship to Patient*
Insurance Co.*
Subscriber ID #*
Group #*
Subscriber’s Employer*
Subscriber’s D.O.B.

MonthDayYear
Date
Assignment And Release
I certify that I, and/or my dependent(s), have insurance coverage with blanks* and assign directly to Greg R. Diamond DDS/ Dr. Natalie Yam all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
Greg R. Diamond DDS/ Dr. Natalie Yam may use my health care information and may disclose such information to the above-named Insurance Company and their agents for the purpose of obtaining payment for services rendered 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, whichever occurs later.
Secondary Dental Insurance
Does the patient have secondary dental insurance?

YesNo
Who is responsible for this account?*
Relationship to Patient*
Insurance Co.*
Patient Ss/ ID # (If different from above)
Group #*
If The Insurance Subscriber Is Not The Patient, Provide Information Below Only If Different From Above:
Subscriber’s Address

Street Address

Street Address Line 2

CityState

Zip Code
SUBSCRIBER’S ID/ SS #
Subscriber’s D.O.B.

MonthDayYear
Date
Subscriber’s Employer
Financial Agreement
In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time services are rendered, or within five (5) days of billing if credit shall be extended, unless other financial arrangements are made. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of the patient must be determined before treatment.

I agree that parents or guardians are responsible for all fees and services rendered for treatment of a minor/ child.

All emergency or urgent dental services, or any dental services performed without previous financial arrangements, must be paid for at the time services are performed.

Dental Insurance Benefits: Patients who carry dental insurance plans that the Doctor does not participate with understand that all dental services furnished are charged directly to the patient and that he/ she is personally responsible for payment. We will gladly help prepare the patient’s insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient’s account. We cannot render services under the assumption that our charges will be paid by an insurance company. I understand that filing a claim with my insurance company does not relieve me of my responsibility for payment of all charges.

A service charge of 1.5% per month (18% annum) on the unpaid balance may be charged on all accounts exceeding 60 days, unless previous arrangements are satisfied.

I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.

I further agree that waiver or breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I grant permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form. I have read and understood the above conditions of treatment and payment and agree to their content.
Signature of Patient, Parent, Guardian or Personal representative*

Clear
Date*

MonthDayYear
Date

Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that health providers keep your medical and dental information private. The HIPAA privacy rule states that health providers must also provide patients with a written Notice of Privacy Practices. This notice is dated January 2008. The Privacy Practices described will be in effect after this date and until or if they are replaced. You may obtain additional copies of this Notice upon request.
Uses and Disclosure of Information
Treatment Services
We may use or provide your health information to all of our staff members, other dentists, your physicians, and/or other healthcare providers taking care of you. We may also provide mail, phone or electronic contacts as appointment reminders, recommendations of treatment alternatives, information about other health services and/or other office services.

Payment and Operations
We may provide your health information as required to allow for payment for services and participation in quality assurance, disease management, training, licensing, and certification programs.

Marketing
We will not use your health information for marketing purposes without your written consent.

Legal Requirements
We may disclose your health information when required by law.

Threat to Health and Safety
If abuse or neglect is reasonably suspected, we may disclose your health information to the appropriate governmental authorities.

National Security
When required, we may disclose military personnel with health information to the Armed Forces. Information may be given to authorized federal official when required for intelligence and national security activities.

Family Members, Friends, and Others Involved in Care
At your request, we may disclose your health information to a family member or other person if necessary to assist with your treatment and/or payment for services. Based on our judgment and as per 164.522(a) of HIPAA we may disclose your information to these persons in the event of an emergency situation. We also may make information available so that another person may pick up filled prescriptions, medical supplies, records, or x-rays for you. Your information may be disclosed to assist in notifying a family member, care-giver, or personal representative of your location or condition.

Patient Rights
You have the right to see your information and receive copies of your records under most circumstances. Your request must be in writing addressed to the contact officer. You may be charged for the cost of making copies including the actual copies and staff time. Postage will be added if copies are requested to be mailed. A summary of your health information can also be requested for a fee.

You may request a listing of any situations where we or our business associates disclosed your health information for purposes other than treatment, payment, or other activities for the last six years. You may be charged for costs associated with our response.

You may request that we observe additional restrictions on the disclosure of your information. We are not required to agree to these restrictions, but we may do so (except in case of an emergency).

If you believe that changes should be made to your health information, you must request this in writing. You must provide an explanation as to why changes should be made. Even with your request, changes may be refused under certain circumstances.

If you would like to receive your health information in an alternate format or at a specified location you must make your request in writing.
Acknowledgement of Receipt of Notice of Privacy Practices
By signing this form I confirm that I have had the opportunity to receive a copy of the Notice of Privacy Practices.
Print Name*
Sign Name*

Clear
Date*

MonthDayYear
Date
Should be Empty: