ludi crownover - cheneweth shelly · ludi crownover ludi crownover patient coordinator . 236...

236 Hospital Dr. Suite A, Ukiah CA 95482 / phone 707.468.0444 / www.beautifulsmilesofukiah.com

We are delighted to welcome you to our office and are pleased that you have chosen us to

serve your dental needs. We provide outstanding dental care and are proud of our dedication

to our patients. Our goal is to help you look and feel your very best!

In order to facilitate being seen as soon as possible at the time of your appointment, we would

appreciate if you would complete the enclosed Patient Registration Forms before your arrival.

Please remember to bring it with you at the time of your appointment. Also, if you enjoy the

benefits of dental insurance you should bring your card for us to copy and keep on file. We will

be happy to bill your insurance and will only ask for your co-pay at the time of service.

If you are unable to make the appointment you have scheduled with us, please notify us at least

48 hours in advance. We would be glad to reschedule the appointment at a more convenient

time, if necessary. In the meantime, we look forward to meeting you and serving your needs.

Thank you again for choosing our office, where lives are changing daily!

Sincerely,

Ludi Crownover

Ludi Crownover

Patient Coordinator


DIRECTIONS

Our office is located on Hospital Drive in Ukiah. Turn left at the first driveway after Walgreens.

Address: 236 Hospital Drive Suite A, Ukiah, CA 95482

From Highway 101:

Take the Perkins Street Exit, toward Central Ukiah

Head West on Perkins Street

Turn Right onto Hospital Drive

Take the 1st driveway on the Left after Walgreens

We are the 3rd building on the right, 236 Suite A.

From State Street:

Head toward the Courthouse

Turn East onto Perkins Street

Take the 3rd left, onto Hospital Drive

Take the 1st driveway on the Left after Walgreens

We are the 3rd building on the right, 236 Suite A.


REGISTRATION

Date: ___________________

Patient Full Name: _____________________________________________________________________

Preferred First Name: __________________________________ Sex (please circle): Female or Male

Birthdate: ____________________________________________________________________________

Social Security Number: _________________________________________________________________

Please Check One of the Following: ____Married _____Widowed ____Single ____Minor

____Separated ____Divorced ____Partnered for_____years

Contact information:

Mailing Address: ______________________________________________________________ _

City: _____________________________ State: ___________ _Zip Code: _______________________

Home phone: _____________________ ______Work:___________ __ _________Ext.___________

Cell phone: _________________ __________Email:_______________________ ____________

Preferred form of contact: ☐Home Phone ☐Work Phone ☐Cell Phone (text) ☐Email

Patient Occupation: _______________________________________________________________ ____

Employer/School: __________________________________________________________ ____

Employer/School Phone #: ____________________________________________ ___________

Spouse or Partner Name: ________________________________________________________________

Spouse/Partner Birthdate: _________________Spouse/Partner S.S.#: ________ _________

Spouse/Partner Employer: _____________________________________________________________

In-Case-of-Emergency Contact Person (someone who does not live in your household):

Name: _____________________________________________Relationship:_____________ ___

Home phone: ___________________________ Cell phone: _______________________ ______

Whom may we thank for referring you? _____________________________________ _____

Please see reverse side.


INSURANCE BENEFITS

Patient

Name Date

Insured’s

Name Carrier

Insurance

Phone # Group #

Insured’s

ID# or SS# Patient

Soc. Sec. #

Insured’s

Birth date Patient

Birth Date

Coverage Anniversary Date

Annual

Maximum

Remaining

Benefits


FINANCIAL AGREEMENT

This agreement is to inform you of your financial obligation to our practice. We are committed to providing you the most comprehensive dental care using only the highest quality materials and technology available in the market today.

FINANCIAL OPTIONS FOR YOUR TREATMENT: 1. Payment in full: (on or before treatment day)

5% savings for cash and/or check on amounts over $300.

5% senior discount (age 65 and over) offered to those paying with cash and/or check, not to be combined with any other discount.

2. Pre-payment: (before work is started)

Weekly, bi-weekly, or monthly. 3. CareCredit:

12 months interest free

We submit the application

Quick and easy application process

We usually hear back in 24 hours-sometimes during your visit

You can finance up to $25,000-if approved

No down payment

Begin treatment immediately

Just ask one of our team members for an application 4. We accept all major credit cards:

Including Visa, MasterCard, and Discover.

PATIENTS WITHOUT INSURANCE COVERAGE: We provide written estimate of fees, and payment is expected at each visit for service rendered.

PATIENTS WITH INSURANCE COVERAGE: All charges that you incur for any treatment provided are your responsibility regardless of your insurance coverage, which can be inadequate with some dental plans. Dental insurance is a benefit used to assist you, not to dictate necessary treatment. As we work with you to reach your optimum oral health, we do require that the estimated co-payment for treatment be paid at the time of service. This is the portion of our fees that your insurance coverage does not assist you with. Your estimated co-payment may be adjusted after the time of treatment depending upon the final reconciliation of insurance payments.

Our practice will accept an assignment of benefits from your insurance company and it is important to understand that the agreement regarding your dental benefits is between you, your employer, and your

Please see reverse side


insurance company. Although we are willing to submit dental claims on your behalf, we do not accept responsibility for the outcome of the transaction. Completing insurance forms is a courtesy we extend in an effort to save you time and facilitate payment to our practice from your insurance company. By having our practice process your insurance forms, it is important that you understand that this does not eliminate your financial obligation. Insurance payments are received within 30-60 business days from the time of billing. If your insurance company has not made payment to our practice within 60 days, we will ask you to pay the entire balance at that time and you will be responsible for seeking reimbursement from your insurance company. Our practice does not guarantee that your insurance company will assist you with the payment for treatment you receive from our practice. If your claim is denied, you will be responsible for paying the full amount at that time. Our practice will not enter into a dispute with your insurance company over any claim, although we will provide necessary documentation your insurance company requests to sort out any confusion or questions that many arise. It is your responsibility to resolve any type of dispute over payments made or not made by your insurance company to our practice. Cancellations and rescheduling dental visits: Once an appointment has been made, that time is reserved specifically for you. We do require 48 business hours of notice to cancel/reschedule existing visits with us. If we do not receive such notice, you will be asked to secure your following appointment with a $50 refundable fee. This fee will only be applied to appointments cancelled without 48 business hours of notice. RETURNED CHECKS: A $25.00 charge applies when a check is returned by the bank. FINANCE CHARGES: Finance charges will be applied to all balances not paid within 25 days of the monthly billing date. A late charge of 1.5% on the balance then unpaid and owed will be assessed each month until paid. It is your responsibility to ensure your insurance company pays promptly so you can avoid finances charges. 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. 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. I HAVE READ AND ACCEPT THE TERMS OF CONDITIONS OF THE FINANCIAL AGREEMENT AND I AUTHORIZE MY INSURANCE COMPANY TO PAY MY DENTAL BENEFITS DIRECTLY TO THE PRACTICE.

Print Name of Patient or Responsible Party

Signature of Patient or Responsible Party Date


DENTAL HEALTH HISTORY

Date: Patient Name: _______________________________________________

Welcome to our practice! We appreciate the confidence you place with us to provide dental services. To assist us in serving you, please complete the following forms. The information provided on this form is important to your dental health. If there have been any changes to your health, please tell us. If you have any questions, please do not hesitate to ask. Yes No Yes No

Are you apprehensive about dental treatment? ☐ ☐

Have you had problems with previous

dental treatment? ☐ ☐

Do you gag easily? ☐ ☐

Do you wear dentures? ☐ ☐

Does food catch between your teeth? ☐ ☐

Do you have difficulty chewing your food? ☐ ☐

Do you avoid brushing any part of your mouth

because of pain? ☐ ☐

Do your gums bleed when you brush or floss? ☐ ☐

Do your gums feel swollen or tender? ☐ ☐

Have you ever noticed slow-healing sores in or

around your mouth? ☐ ☐

Are your teeth sensitive? ☐ ☐

Do you feel twinges of pain when your teeth

come in contact with:

Hot foods or liquids? ☐ ☐

Cold foods or liquids? ☐ ☐

Sweets? ☐ ☐

Do you take fluoride supplements? ☐ ☐

Do you have chronic bad breath? ☐ ☐

Do you have blisters on your lips or mouth? ☐ ☐

Do you have a burning sensation on your tongue?☐ ☐

Do you have dry mouth? ☐ ☐

Do you primarily breathe through your mouth? ☐ ☐

Do you bite your fingernails? ☐ ☐

Do you bite your lips or cheeks? ☐ ☐

Do you have any loose teeth or broken fillings? ☐ ☐

Have you had orthodontic (braces) treatment? ☐ ☐

Have you had gum surgery or deep cleanings? __ ☐ ☐

Does your jaw make noise so that it

bothers you or others? ☐ ☐

Do you clench or grind your jaw frequently? ☐ ☐

Does your jaw ever feel tired? ☐ ☐

Does your jaw get stuck so that

you can’t open freely? ☐ ☐

Do you have any jaw symptoms or headaches

upon waking in the morning? ☐ ☐

Have you had a jaw trauma or injury? __ ☐ ☐

Have you ever had a night guard? ☐ ☐

Do you take medications or pills for pain or

discomfort (pain relievers, muscle relaxants,

antidepressants)? ☐ ☐

Do you have pain in the face, cheeks, jaws,

joints, throat, or temples? ☐ ☐

Do you have earaches or pain

in front of the ears? ☐ ☐

Are you a habitual gum chewer or pipe smoker? ☐ ☐

Have you ever had Botox or filler? ☐ ☐

Are you interested in Botox for cosmetic or therapeutic

reasons? _________________________ ☐ ☐

Are you dissatisfied with

the appearance of your teeth? ☐ ☐

Would you like any cosmetic options for your smile?☐ ☐

How often do you brush? __________________________

How often do you floss? ___________________________

MEDICAL HEALTH HISTORY

Do you have, or have you had, any of the following?

Yes No

Heart Problems___________________________ ☐ ☐

Chest pain ☐ ☐

Shortness of breath ☐ ☐

Blood pressure problem ☐ ☐

Heart murmur ☐ ☐

Heart valve problem ☐ ☐

Rheumatic fever ☐ ☐

Pacemaker ☐ ☐

Artificial heart valve ☐ ☐

Blood Problems ☐ ☐

Easy bruising ☐ ☐

Abnormal bleeding ☐ ☐

Blood disease (anemia) ☐ ☐

Ever require a blood transfusion? ☐ ☐

Allergy Problems ☐ ☐

Hay fever ☐ ☐

Sinus problems ☐ ☐

Skin rashes ☐ ☐

Taking allergy medication ☐ ☐

Asthma ☐ ☐

Intestinal Problems ☐ ☐

Ulcers ☐ ☐

Weight gain or loss ☐ ☐

Special diet ☐ ☐

Kidney or bladder problems ☐ ☐

Bone or Joint Problems ☐ ☐

Arthritis ☐ ☐

Back or neck pain ☐ ☐

Joint replacement ☐ ☐ (e.g., total hip or knee)

Pre-medications required by physician ☐ ☐

Diabetes_______________________ ____ ☐ ☐

Urinate more than 6 times a day ☐ ☐

Thirsty/mouth is dry most of the time ☐ ☐

Family history of diabetes ☐ ☐

If known, A1C:_____________________

Date: _____________________________

Have you had an allergic reaction to: Yes No

Local anesthetics (“Novocaine”) ☐ ☐

Penicillin or other antibiotics ☐ ☐

Sulfa drugs ☐ ☐

Barbiturates, sedatives, or sleeping pills ☐ ☐

Aspirin, Acetaminophen, or Ibuprofen ☐ ☐

Codeine, Demerol, or other narcotics ☐ ☐

Reaction to metals ☐ ☐

Latex or rubber dam ☐ ☐

Other___________________________________

If No Known Allergies please circle here ------------- NONE

Fainting Spells, Seizures, or Epilepsy ☐ ☐

Stroke(s) ☐ ☐

Frequent or severe headaches ☐ ☐

Thyroid problems ☐ ☐

Persistent cough or swollen glands ☐ ☐

Cancer/Tumor ☐ ☐

Tuberculosis or other respiratory disease ☐ ☐

Do you drink alcohol? If so, how much? ☐ ☐

Do you smoke? If so, how much? ☐ ☐

Do you chew tobacco? ☐ ☐

Are you interested in stopping tobacco use? ☐ ☐

History of alcohol or drug abuse? ☐ ☐

Hepatitis, jaundice, or liver trouble ☐ ☐

Herpes or other STD ☐ ☐

HIV-positive/AIDS ☐ ☐

Glaucoma ☐ ☐

Do you wear contact lenses? ☐ ☐

History of head injury? ☐ ☐

Do you have any disease, condition, or problem not listed

previously that you feel we should know about? ☐ ☐ -If so, please describe: _____________________

Women Only

Are you taking contraceptives or

other hormones? ☐ ☐

Are you pregnant? ☐ ☐ If so, expected delivery date: ____________________

Are you nursing? ☐ ☐

Medications List any medications you are currently taking and why you take

them: _____________ __________________________ _______________________________________________________________________________________________________________________________________ __________________________________________________________________________________________

_______________________________________________________

Print Patient Name: ______________________________________________ Current Physician’s Name__________________________

Patient/Parent Signature: __________________________________________ Preferred Pharmacy______________________________ Dentist Signature: ________________________________________________


STATEMENT OF PRIVACY PRACTICES We, at Shelly Cheneweth, DDS, are dedicated to protect the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee to ensure that your health information is never compromised is a principle concept of our practice. We may, from time to time, amend our privacy policies and practices but will always inform you of any changes that might affect your rights.

Protecting Your Healthcare Information We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and Accountability Act and the state of California. This includes the issues relating to your treatment, payment, and our dental care operations. However, your personal protected health information will never be otherwise given to anyone – even family members – without your written consent. You, of course, may give written authorization for us to disclose your information to anyone you choose, for any purpose. Our offices and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality of your records is always protected. Our privacy policy and practices apply to all former, current, and future patients, so you can be confident that your protected health information will never be improperly disclosed or released.

Collecting Protected Health Information We will only request personal information needed to provide our standard of quality dental care, implement payment activities, conduct normal dental practice operations and comply with the law. This may include your name, address, telephone number(s), Social Security number, employment data, medical history, health records, etc. While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, the information will always be protected to the full extent of the law.

Disclosure of Your Protected Health Information As stated above, we may disclose information as required by law. We are also obligated to provide information to law enforcement officials under certain circumstances. We will not use your information for marketing purposes without your written consent. We may use and/or disclose your health information to communicated reminder about your appointments including voicemail messages, answering machines, emails, and post cards.

Patient Rights You have a right to request copies of your healthcare information; to request copies in a variety of formats; and to request a list of instances in which we, or our business associates, have disclosed your protected information for uses other than stated above. All such requests must be in writing. We may charge for your copies in an amount allowed by the law. If you believe your rights have been violated, we urge you to notify us immediately. You can, also, notify the U.S. Department of Human Services. We thank you for being a patient at Shelly Cheneweth, DDS. Please let us know if you have any questions concerning your privacy rights and the protection of your personal health information.



ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES

I acknowledge that I have received a copy of the Notice of Privacy Practices for the office of Shelly

Cheneweth, DDS. The Notice of Privacy Practices describes the types of use and disclosures of my protected

health information that might occur in my treatment, payment for services or in the performance of the

office’s health care operations. The Notice of Privacy Practices also describes my rights and the

responsibilities and duties of this office with respect to my protected health information. The Notice of

Privacy Practices is also posted in the facility. Shelly Cheneweth, DDS reserves the right to change the privacy

practices that are described in the Notice of Privacy Practices. If privacy practices change, I will be offered a

copy of the revised Notice of Privacy Practices at the time of my first visit after the revisions become

effective. I may also obtain a revised Notice of Privacy Practices by requesting that one be mailed to me.

ADDITIONAL DISCLOSURE AUTHORITY

In addition to the allowable disclosures described in the Notice of Privacy Practices, I hereby specifically

authorize disclosure of my protected health care information to the persons indicated below. Please check

ALL below:

ANY MEMBER OF MY IMMEDIATE FAMILY ____YES ____NO

SPOUSE or PARTNER ____YES ____NO

OTHER (PLEASE SPECIFY):_____________ ____YES ____NO

______________________________________ X__________________________________________

Name of Patient Signature (Patient or Responsible Party)

________________ ____________________________________________________________

Date Relation of the Responsible Representative to the Patient

ludi crownover - cheneweth shelly · ludi crownover ludi crownover patient coordinator . 236...

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