Patient Information Form Full Name: Date of Birth: / / Gender: M or F SS#: Marital Status: Single Married Widowed Divorced Employment Status: Employed Unemployed Retired Disabled Address: City: State: Zip: County Home Phone: ( ) Cell: ( ) Work Phone: ( ) Email: Preference for appointment confirmations: Text Phone E-mail Responsible Party (if patient is a minor) Parent/Guardian Contact Name: Phone: ( ) Address: _ City: State: Zip: Date of Birth: / / SS#: Marital Status: S M W D Medicaid ID Number: Insurance Subscriber Name: Relationship: Subscriber Full Address: City: State: Zip: Subscriber Social Security # Date of Birth: / / Employer:_ Employer Address: Plan Name: Group #: Insurance Co. Name and Address: Emergency Contact Information: In case of an Emergency please contact the following person: Name: Relationship to Patient: Phone: ( ) Address: Race: Please indicate what best describes your Race: White (including White of Latino/Hispanic Descent) Asian Other African American (including African American of Latino/Hispanic Descent) Veteran Status: Have you ever been in the armed forces of the United States? Yes No Consent for Services and Care: I authorize Sentara Halifax Dental Clinic to treat the above named patient and disclose, when requested, any and all information for any illness or injury, medical history consultation, prescriptions or treatment and copies of all medical records. I assign or authorize direct payment to the designated practiced toward any medical procedures performed and authorize Sentara Halifax Dental Clinic to file claims on my behalf. I agree that this authorization shall be valid until rescinded in writing or replaced by one of a later date. A photocopy of this authorization shall be considered effective and valid as the original. I understand that I am responsible for services not covered by my insurance plan or if my insurance is not in effect at the time of service. I understand that Sentara Halifax Dental Clinic renders services without regard to race, creed, color or national origin. By my signature I acknowledge that I have been informed of Virginia state laws regarding blood testing: In event that a health care provider or employee is exposed to the patient s bodily fluids in a manner which may transmit disease, the patient will be deemed to have consented to testing for HIV and hepatitis and to release or disclosure of the test results to that health care provider or employee. Signature: Date: / / Printed Name: Relationship to Patient: Revised 1/15
Consent To Treat I, the undersigned, hereby consent to and authorize the administration and performance of all treatments, the administration of any needed anesthetics; the performance of such procedures as may be deemed necessary or advisable in the treatment of this patient, the use of prescribed medication; the performance of diagnostic procedures; the taking and utilization of cultures and performance of other medically accepted laboratory test, all of which in the judgment of the attending dentist or their assigned designees, may be considered medically necessary or advisable. I fully understand that this consent applies to Sentara Halifax Dental Clinic. I fully understand that this consent is given in advance of any specific diagnosis or treatment. I intend this consent to be continuing in nature even after a specific diagnosis has been made and treatment recommended. The consent will remain in full force until revoked in writing. I hereby authorize Sentara Halifax Dental Clinic to release medical information to any of my physicians or insurance companies that may be pertinent to my case. I hereby authorize payment directly to Sentara Halifax Dental Clinic of benefits otherwise payable to me. I hereby authorize release of my medical records to third party insurers or other authorized persons to whom disclosure is necessary to establish or collect a fee for the services provided. I understand that I am financially responsible for charges not covered by this authorization. A photocopy of this authorization shall be considered as valid as the original. Further, I acknowledge that if I am indebted for past due charges that I am financially responsible for those charges also. I consent and authorize Sentara Halifax Dental Clinic to collect my personal medical information in order to obtain and maintain on file the information necessary to verify and process electronic prescriptions. The received information can include prescription insurance eligibility, prescription insurance claims history, and prescription insurance formulary files. I consent and authorize Sentara Halifax Dental Clinic to transmit prescription information to the pharmacy of my choice through a third party intermediary operating under a business associate agreement with the electronic prescription software vendor. MEDICARE PATIENTS: I authorize Sentara Halifax Dental Clinic to release medical information about me to the Social Security Administration or its intermediaries for my Medicare claims. I assign the benefits payable for services to the appropriate Sentara Dominion Health Medical Associates affiliate practice. In accordance with the provisions of Section 32.1-45.1 of the Code of Virginia, (whenever any healthcare provider, or any person employed by or under the direction and control of a health care provider, is directly exposed to body fluids of a patient in a manner which may, according to the current guidelines of the Centers of Disease Control, transmit human immunodeficiency virus), the patient whose body fluids were involved in the exposure shall be deemed to have consented to testing for infection with human immunodeficiency virus. If there is an exposure, and the patient s test is positive, the attending dentist will notify the patient, any person exposed and the Virginia Health Department and appropriate counseling will be offered. I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents. Patient s Signature (or responsible party) Date: 1/15
Patient Name: Date of Birth: Although 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 medications that you may be taking, could have an important interrelationship with the dentistry you receive. Thank you for answering the following questions. Are you under a physician's care now? Y or N If yes, please explain: Physician Name: Physician Phone #: Have you ever been hospitalized or had a major surgery? Y or N If Yes, please explain: appointment: Dentist Name: Are you taking any medications, pills, or drugs? Please list all medications you are currently taking: Do you use tobacco Y or N Do you use controlled substances? Y or N Are you pregnant, trying to get pregnant? Y or N Taking oral contraceptives? Y or N Nursing? Y or N Are you allergic to any of the following? Please circle Aspirin Penicillin Codeine Acrylic Metal Latex Local Anesthetics Food Allergies Sulfa Drugs Other: Do you have, or have you had, any of the following? Please circle AIDS/HIV Positive Heart Conditions Stomach/Intestinal Disease Alzheimer's Hemophilia Swelling of Limbs Anaphylaxis Hives and/or Rash Thyroid Conditions Anemia Herpes Tumors or Growths Arthritis/Rheumatism Kidney Problems/Dialysis Ulcers Artificial Parts Liver Disease Venereal Disease Broken Jaw Lung Disease Glaucoma Blood Disease Pain in Jaw Joints Chemical Dependency Psychiatric Care Convulsions/ Seizures Recent Weight Loss/Gain Diabetes/Hypoglycemia Shingles Fainting Spells/Dizziness Sickle Cell Disease Frequent Headaches Spina Bifida Heart Murmur/Mitral Valve Prolapse High Blood Pressure Rheumatic Heart Disease Prosthetic Joints, Pins, Screws in Body Diabetes Asthma/Breathing Problem/Emphysema Rheumatic Fever Radiation Treatment or Chemotherapy Take Blood Thinners (i.e. Coumadin, Heparin, Plavix) Have you ever had a serious illness not listed above? If Yes please explain: Dental: Do you like your smile? Y or N What are your current dental concerns? 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. Signature of patient, parent, or guardian: Provider Signature: January 2015 Date: Date:
Patient Acknowledgement 1. All appointments not covered by Medicaid are to be paid in full before the appointment can be made. LMI fee is $35.00 for an appointment and it is nonrefundable! NO EXCEPTIONS. Medicaid 21 and over: Medicaid will only pay for one comprehensive exam, 2 limited exams per calendar year, necessary x-rays and any medically necessary extractions. 2. If you are late for your scheduled appointment we have the right to reschedule. It is encouraged to arrive 15 minutes prior to your scheduled appointment to allow proper time to register. 3. Our office enforces a very strict no show and cancellation policy. Sentara Halifax Dental Clinic has a very strict cancellation and no show policy. If you cancel without a 24 hours notice or no show for an appointment there will be a 60 day wait for reappointment. There is also a $35.00 charge for appointments that are canceled without a 24 hour notice or for no shows. We understand that sometimes you need to cancel or reschedule your appointment; however we request you call to cancel as soon as possible. By cancelling your appointment with proper notice we are able to help other patients who are in pain or waiting to be seen. If there continues to be a documented history of no shows or last minute cancellations, it shall be the discretion of the dentist whether a patient is dismissed and the duration of any dismissal. Please list two additional contacts who we may contact to reach you in reference to your appointments or in case of an emergency. TWO CONTACTS ARE MANDATORY FOR EVERY PATIENT. 1. Name: Phone: Relationship: 2. Name: Phone: Relationship: PERIODIC EXAMS: We encourage all patients to follow through with their suggested treatment plan as directed. Halifax Regional Dental Clinic requires all patients to have a six-month periodic exam regardless of the status of their treatment plan. If you have not completed your treatment within six months of your last exam you will be required to have a periodic exam before further treatment will be completed. The fee for the exam is $35.00. This is a quality of care standard for the office and the patient. There will be no exceptions to this policy. I acknowledge I have read over the Patient Acknowledgement. Patient Name: Signature of Patient or Responsible Party: Revised January 2015 Date:
SUMMARY NOTICE OF PRIVACY PRACTICES This is a summary and the detailed 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. Sentara collects health information from you and stores it in a chart and on a computer. This is your medical record. The medical record is the property of Sentara, but the information in the medical record belongs to you. Sentara protects the privacy of your health information. The law permits Sentara to use or disclose your health information for the following purposes: Treatment : Example: a Sentara nurse may read your medical chart in order to care for you Payment: Example: We may send information about you to your insurance company in order to get paid. Regular Health Care Operations: Example: We may provide health information to students who are authorized to receive training in our facility. As a Patient you have the following rights: Right to Notice of Privacy Practices Right of access and inspection Right to amend Right to authorize non-treatment uses Right to accounting of disclosures Right to request restrictions on use Right to request alternative channels of communication Right to complain to entity or HHS Effective Date of this notice: 04/14/2003 Updated August 2013. ACKNOWLEDGEMENT OF RECEIPT This is to acknowledge that I have received this Summary Notice of Privacy Practices and been offered a written copy of the Sentara Notice of Privacy Practices or to access via the internet. http://www.sentara.com/policies/pages/websitepolicies.aspx or http://www.hrhs.org Name: Signature: Date: Relationship if other than patient: Acknowledgement of Receipt Notice of Privacy Practice Rev. 1/15 Pg 1 of 1
No-Show Policy Purpose: To guide the management of dental patients who do not keep appointments, cancel without sufficient notice (defined as less than 24 hours) or show up more than 15 minutes late for their scheduled appointment and maximize access to care for those patients who are responsible about keeping appointments. Procedure: 1. All new patients of Sentara Halifax Dental Clinic will be given a copy of the No-Show Policy and be required to sign an acknowledgement of the policy, which will be placed in their dental record. 2. As a courtesy, patients will be reminded of their scheduled appointments two days in advance of their appointment. Patients, however, are still responsible for their appointments regardless of a successful reminder. Appointments will be removed for patients with non-working telephones. If the patient s voice mail is reached, the patient will be asked to call the dental clinic no later than noon of the following day to confirm their intention to keep the appointment. Appointments will be removed for patients that do not call back to confirm. Patients whose appointments have been removed for either of these reasons who show up for their appointments will be offered the opportunity to sit and wait to be worked in or rescheduled for another day. 3. Patients who do not arrive for an appointment, cancel with less than 24 hours notice or show up more than 15 minutes late will be documented as a no-show and will be charged a $35.00 no-show fee. These patients will not be able to reschedule an appointment for 60 days. They will then be placed on same day or quick call status. 4. Patients who miss a second appointment within the same calendar year, cancel with less than 24 hours notice or show up more than 15 minutes late will be documented. All future appointments for these patients will be cancelled and they will not be allowed to reschedule for 90 days. 5. Patients who have failed to comply with the no-show policy will no longer be allowed to schedule appointments. If they fail to show, cancel, or show up more than 15 minutes late for appointments a third time they will be terminated from Sentara Halifax Dental Clinic. 6. Low to moderate income patients who no-show will forfeit their $35.00 payment. 7. This policy will be enforced uniformly and consistently by all staff and administration of Sentara Halifax Dental Clinic. Revised January 2015
PERMISSION TO DISCUSS PERSONAL HEALTH INFORMATION (PHI) Patient Name: Date of Birth: Account Number: NAME RELATIONSHIP _ Signature of Patient, Parent or Guardian: Date: In order to obtain information by telephone, the party calling the practice must share the patient identifier with the staff. Patient identifier: (Patient Date of Birth) Reviewed 1/15