Patient Form - Rochester, MN

PERSONAL INFORMATION

Full Name Last Name

First Name

Middle Intial

Preferred Name

Address

City

State

Zip

Email

Home Phone

Wk Phone

Cell Phone

Sex Male Female

Birth Date

Age

SS#

Your Occupation

Employer/School

Employer/School Phone

Spouse/Parent Name

Spouse/Parent Employee

Spouscs/Parent Business Phone

Spouse/Parent Social Security

Who is responsible for account?

Emergency Contact Name

Relationship

Phone

Who may we thank for referring you to this office?

DENTAL INSURANCE INFORMATION

Primary

Insurance Company Name

Phone

Primary Policy Carrier’s Name

DOB

Group#

ID#

Insurance Company Address

City

State

Zip

Secondary

Insurance Company Name

Phone

Primary Policy Carrier’s Name

DOB

Group#

ID#

Insurance Company Address

City

State

Zip

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES (HIPPA)

I acknowledge that I have received, reviewed, understand and agree to the Notice of Privacy Practices of kelly Dental, which describes the Practice’s policies and procedures regarding the use and disclosure of any of my Protected Health Information created, received or maintained by the Practice.

Patient’s/Parent Signature

Date

Witness

Please turn over for more important information that requires your signature. Thank you.

CONSENT FOR PURPOSES OF TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS

I consent to kelly Dental (“the Practices”) use and disclosure of my Protected Health Information for the purpose of providing treatment to me, for the purpose relating to the payment of services rendered to me, and for the Practice’s general healthcare operations purposes. Healthcare operations purposes shall include, but not limited to, quality assessment activities, credentialing, business management and other general operation activities. I understand that the Practice’s diagnosis or treatment of me may be conditioned upon my consent as evidenced by my signature on the document.

For purposes of this Consent, “Protected Health Information” means any information, including my demographic information, created or received by the Practice, that relates to my past, present, or future physical or mental health condition; the provision of health care to me; or the past, present, or future payment for the provision of healthcare services to me; and that cither identifies me or from which there is a reasonable basis to believe the information can be used to identify me.

I understand I have the right to request a restriction of the use and disclosure of my Protected Health Information for the purposes of treatment, payment or healthcare operations of the Practice, but the Practice is not required to agree to these restrictions. However, if the Practice agrees to a restriction that I request, the restriction is binding on the Practice.

I understand that I have the right to review the Practice Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes my rights and Practice’s duties regarding the types of uses and disclosures of my Protected Health Information.

I have the right to revoke this consent, in writing, at any time, except to the extent that a Physician or the Practice has acted in reliance on this consent.

Fees are payable when services are rendered unless other arrangements are made. 1, undersigned, hereby authorize the kelly Dental Dentists , and whomever they may designate as their assistant(s) to perform diagnostic tests, including but not limited to radiographs, and to administer treatment as is necessary. I also certify that no guarantee or assurance has been made to the results that may be obtained. I understand that The Practice is required to maintain original records and x-ray films as property.

Signature of Patient or Personal Representative

Date

Name of Personal Representative

Personal Representative’s Authority

INSURANCE INFORMATION

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and me, Furthermore, I understand that kelly Dental will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this office will be credited to my account upon receipt. I permit this office to endorse remittances for the conveyance of credit to my account. HOWEVER, 1 CLEARLY UNDERSTAND AND AGREE THAT ALL SERVICES RENDERED TO ME ARE CHARGED DIRECTLY TO ME AND I AM PERSONALLY RESPONSIBLE FOR PAYMENT.

Patient’s/Parent’s Signature

Date

Witness

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

I authorize the release of any medical information necessary to process my insurance claim(s) and also certify that all Insurance information given to this clinic is correct and complete.

Patient’s/Parent’s Signature

Date

Witness

REQUEST FOR PAYMENT OF BENEEFITS TO PROVIDER OF CARE

I hereby authorize my insurance company/administrator to pay by check, and for it to be mailed directly to: kelly Dental, 338 W. Broadway, PO Box 518, kelly, MN 55964 the expenses benefits allowable and otherwise payable to me under my current policy, as payment toward the total charges for professional services rendered. [ have agreed to pay, in a current manner, any balance of said professional charges. I agree that this office be given power of authority to endorse/sign my name on any and all drafts for payment of my bill.

CONSENT FOR TREATMENT OF MINOR

I hereby authorize Dentists of kelly Dental and whomever they may designate as their assistant(s), to perform diagnostic tests, including but not limited to radiography, and to administer treatment as he deems necessary to:

(Child’s Name) , my son/daughter/or power of Authorization(circle one).

Patient’s/Parent’s Signature

Date

Witness