Patient Information

*All fields required

Primary Insurance Information

Secondary Insurance Information

New Patient Medical History Form

In the event of any emergency who is the closest relative we can contact?

Dental History

Medical History

I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly. There are no other medical conditions or medications/allergies that have not been listed. I am aware that I must notify the practice of any future changes.

Patient Acknowledgement and Consent Form

Effective April 14, 2003, the federal law known as the Health Insurance Portability and Accountability Act of 1966 (“HIPAA”) requires that this office comply with certain rules regarding the maintenance of the privacy of your information that we have collected and will collect in the future.

To comply with one of HIPAA’s requirements, we are giving you a copy of our Notice of Privacy Practices. The Notice of Privacy Practices contains the information that HIPAA requires us to disclose regarding our privacy practices.

Existing Michigan Law requires (in addition to our attempt to obtain your written acknowledgement, discussed above) us to first obtain your written consent prior to disclosing any of your information except for our disclosures in connection with: a defense to clain challenging out professional competence; a review entity’s functions; a claim for payment of fees; a third party payer’s examination of our records; a court order as part of a crimanal investigation; an identification of a dead body; a liscense investigation; or a child abuse/neglect investigation.

From time to time it may be necessary for us to make disclosures of your information in connection with your treatment. For example, we may make a referral to or consult with another dentist or health care professional, provide a specimen to a laboratory for testing or otherwise make disclosures of your information in connection with providing or coordinating your treatment.

Patient Responsibility Agreement

Payment is expected at the Time of Service

For all patients, payment of insurance co-pays, deductibles, and services not covered by insurance are to be paid for at the time services are rendered. You are responsible for any balances not covered by your insurance, including rejected claims. While every effort will be made to submit claims in accordance with insurers’ requirement for payment, in the event of a dispute or rejection, you as the insured or guarantor are responsible for payment. Insurance coverage for dental services is a benefit provided to you and the eligible members of your family. The insurance contract is between you and your insurance provider, and not between the insurance company and your dental care provider. It is very unlikely for our dental office staff to predict exactly what your benefits are, since there are so many different insurers and policies. We will do our best to obtain correct information, but we are not responsible for misinformation given by your insurer. Also, be made aware that each insurance policy has a maximum allowed during the contract period. We cannot be held responsible for tracking this information for you. We do not accept Medicaid of MIDA as a form of payment. Also, there are other capitation and HMO insurers for which we are not an authorized provider. You are responsible for checking your plans list of providers ahead of time. If we are not a provider on that list, you will be responsible for payment yourself. We will be happy to provide you with whatever documentation is necessary to pursue your claim for reimbursement for your insurance company.

Payment Responsibility for Divorced / Separated Parents

The person who brought the child in for services is responsible for payment. This office cannot be responsible for payment. This office cannot be responsible for collecting from any other individual.

Missed or Cancelled Appointment Policy

Patients will be charged $50.00 per appointment for failed or cancelled hygiene appointments with less than one business day’s notice. Patients will be charged $100.00 per appointment for failed or cancelled doctor appointments with less than one business day’s notice. Failed or cancelled appointment fees are doubled for evening (5:00 pm or later) and weekend appointments due to high demand and limited availability. The failed or cancelled appointment fee must be paid before the patient can schedule another appointment. Insurance companies do not cover failed or cancelled appointment fee. The patient is responsible to pay the failed or cancelled appointment fee.

I acknowledge that I have read and understand this payment policy.