Demo form Step 1 of 6 16% Patient InformationName(Required) First Middle Last Preferred NameBirth Date(Required) MM slash DD slash YYYY Social Security #(Required)Drivers License(Required)Gender(Required)Make a selectionMaleFemaleOtherMarital Status(Required)Make a selectionSingleMarriedDivorcedSeparatedWidowedPatient Contact InformationAddress(Required)Address2CityCountryAKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYZip(Required)Home Phone(Required)Mobile PhoneWork PhoneEmail Address(Required) For your convenience, our office can communicate with you about your health and our office by email and text message. It’s ok for our office to communicate with you by email It’s ok for our office to communicate with you by text message Patient InformationI acknowledge that I have received a copy of the Statement of Privacy Practices for the practice Bellevue Dentists. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment of services, or in the performance of the office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility. Bellevue Dentists reserves the right to change the privacy practices currently described in the Statements of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me. Additional Disclosure AuthorizationIn addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare Information to the person(s) identified below. Without indicating "Yes" in answer to each individual question, personal protected (PHI) cannot be shared with anyone unless otherwise allowed by HIPAA rules.Spouse only(Required) Yes No Any member of my immediate family (spouse, children, children's spouses)(Required) Yes No Any member of my extended family (parents, grandchildren)(Required) Yes No Other(Required) Yes No Health HistoryAlthough dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.Are you under a physician's care now?(Required) Yes No Have you ever been hospitalized or had a major operation?(Required) Yes No Have you ever had a serious head or neck injury?(Required) Yes No Are you taking any medications pills or drugs?(Required) Yes No Do you take or have you taken Phen-Fen or Redux?(Required) Yes No Have you ever taken Fosamax Boniva Actonel or any other medications containing bisphosphonates?(Required) Yes No Are you on a special diet?(Required) Yes No Do you use tobacco?(Required) Yes No Women: Are you...Women: Are you... Pregnant/Trying to get pregnant? Nursing? Taking oral contraceptives? I’ve checked all above that apply * I’ve checked all above that apply *Are you allergic to any of the following?Are you allergic to any of the following? Aspirin Acrylic Sulfa Drugs Penicillin Metal Local Anesthetics Codeine Latex I’ve checked all above that apply * I’ve checked all above that apply * Financial PolicyThank you for choosing us to provide your dental care. We consider it an honor to have been chosen by you to do so. Our philosophy in serving people is to provide quality dental care in a family friendly atmosphere. This Financial Agreement is indicative of our respect for your right to know ahead of time what our expectations are in the area of finances. If you have any questions or concerns about our Financial Agreement please do not hesitate to ask our business office staff. DENTAL INSURANCE As a courtesy we will gladly file your claims and accept assignment of dental insurance benefits provided you agree to the following: You must provide us with an insurance card and all the information necessary to verify your coverage and file your claim. Your insurance policy is a contract between you, your employer and the insurance company. We are NOT a party to that contract. Our relationship is with you and not your insurance company. You are responsible for our fees and not what your insurance company allows or considers "usual, customary and reasonable" all of which vary from one company to another. Although we may estimate your insurance benefits we are not responsible for their accuracy. Knowledge of benefits as well as benefit amounts, limitations, exclusions, waiting periods, etc. is entirely YOUR responsibility. Receiving our services indicates your acceptance of responsibility to pay regardless of our estimate. All charges not paid by your insurance company are your responsibility regardless of the reason for nonpayment. Not all the services we provide are covered benefits. Benefits differ from one company to another. Fees for non-covered services, along with deductibles and co- payments are due at the time of treatment. PAYMENT POLICY We accept cash, personal checks, debit cards, Visa, MasterCard, and Discover. After dental insurance has paid its portion, a statement is sent to the mailing address on record, for the remaining balance. Payment is expected within 25 days of the statement date, to avoid finance charges. If the insurance company does not pay in full within 45 days, it will be your responsibility to pay the balance due within 2 weeks. We do not file claims for medical insurance. PATIENTS WITHOUT INSURANCE COVERAGE Payment is expected at each visit for services rendered unless prior arrangements have been made. MINOR PATIENTS The parent or guardian accompanying the minor is responsible for full payment. In the case of divorced or separated parents, the parent accompanying the child is responsible for payment, without any exception. This office will not attempt to collect payment from a parent that is not present in the office at that visit. RETURNED CHECKS A $25.00 charge applies when a check is returned by the bank. FINANCE CHARGES AND COLLECTION FEES It is your responsibility to ensure your insurance company pays promptly so you can avoid charges. You agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding account balances. We understand temporary financial problems may affect timely payment of your balance. In those situations, we encourage you to communicate any such problems immediately so we may assist you in the management of your account OVERDUE BALANCE An account with an unpaid balance past 90 days will be sent to the collection agency. At that time, you will be responsible for any and all costs incurred in the collection of your debt: attorney fees, court fees and any other fees associated with the collection of your debt. BROKEN OR MISSED APPOINTMENTS Appointments not kept or changed with less than 48 hours notice are considered broken. Broken appointments prevent others from receiving the dental care they deserve. We take them seriously so please be considerate and inform us in advance if you need to change your appointment. FEE FOR MISSED APPOINTMENT IF 48-HOUR NOTICE NOT GIVEN To reschedule or cancel an appointment, you must notify us at least forty-eight (48) hours in advance to avoid a missed appointment fee of $100/hr. We reserve the right to terminate professional treatment of any patient when scheduled appointments are not kept. RECORDS AND REIMBURSEMENTS Original records including radiographs are the property of this office. If you desire we will provide you with a copy of your record or radiographs for a nominal duplication fee. CONSENT & AUTHORIZATION I hereby do authorize dental treatment and agree to pay all related professional fees. Fees not covered by my dental insurance will be promptly paid upon notification from this office. I have read and understand this document in its entirety, outlining office policies and financial policies of Dr. Mayank Saxena, DDS. Without any reservations, I agree to abide by the policies outlined herein.SignatureName Covid-19 ScreeningThis patient disclosure form seeks information from you that we must consider before treatment decisions in the circumstance of the COVID-19 virus. A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID-19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us. It is also important that you disclose to this office any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.Do you have a fever or above normal temperature?(Required) Yes No Are you having shortness of breath or other difficulties breathing?(Required) Yes No Do you have a cough?(Required) Yes No Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?(Required) Yes No Have you experienced recent loss of taste or smell?(Required) Yes No Are you in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.(Required) Yes No Have you tested positive for COVID-19?(Required) Yes No Have you tested for COVID-19 and are awaiting results?(Required) Yes No Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?(Required) Yes No Have you traveled outside the United States by air or cruise ship in the past 14 days?(Required) Yes No Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)(Required) Yes No Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment. For testing, see the list of State and Territorial Health Department Websites for your specific area's information.Sign Form I consent to use Electronic Records and Signatures (Read Electronic Record and Signature Disclosure)To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.Relationship to patientMake a selectionSelfParentSpouseGuardianOtherName(Required) Insurance InformationDo you have dental insurance or will you be paying for yourself?Do you have dental insurance or will you be paying for yourself?(Required)Please ChooseI have Dental InsuranceI will pay for myselfPrimary Dental Insurance - Insurance CompanyType of PlanPlease ChooseDental InsuranceMedicaidOtherInsurance Company NameSubscriber IDGroup #Medicaid IDPrimary Dental Insurance - InsuredRelationship to patientMake a selectionSelfParentSpouseGuardianOtherPrimary Dental Insurance - EmployerIs the plan through an employer?Make a selectionYesNo Δ
