patient registration montgomery dental arts · 2020-03-17 · dental insurance amounts are...

Patient RegistrationMontgomery Dental Arts

Patient’s First Name: _____________________________ Middle: ______________________ Last: _______________________________ Preferred Name: _____________________________ Date of Birth: _____________________________ Patient is covered by dental insurance: Yes / No Patient is the person responsible for payment: Yes / NoAddress: ___________________________________________________________________________ Apt: ______________ City: ____________________________________________ State: _______________ Zip: _____________________________ Home Ph.: ___________________________ Work Ph. _________________________Ext. _______ Cell: __________________________

Sex: M / F Marital Status: Married / Single / Divorced / Separated / Widowed / Partnered / Minor

Social Security Number: _____________________________ Driver’s License Number: _____________________________ Email: __________________________________________ I would like to receive correspondence via email: Yes / No Text: Yes / NoEmployment Status: Full Time / Part Time / Retired Student Status: Full Time / Part-Time Employer: _____________________________ School: _____________________________ Emergency Contact Name: _____________________________________ Relationship to Patient: _____________________________ Emergency Contact Phone Number: _____________________________ 2nd Contact Number: _____________________________ Who can we thank for referring you to our office? _____________________________

If the Patient is not responsible for payment, please complete this section:Responsible Party First Name: __________________________________ MI: ______________________ Last: _____________________________________ Preferred Name: _____________________________ Date of Birth: _____________________________ Address: ___________________________________________________________________________ Apt: ______________ City: ____________________________________________ State: _______________ Zip: _____________________________ Home Ph.: ___________________________ Work Ph. _________________________Ext. _______ Cell: __________________________Social Security Number: _____________________________ Driver’s License Number: _____________________________ Email: __________________________________________ I would like to receive correspondence via email: Yes / No Text: Yes / No

If the Patient has Dental Insurance, please complete this section:Policy Holder’s Name: ___________________________________ Patient’s Relationship to the Policy Holder: _____________________ Policy Holder’s SSN: _____________________________________ Policy Holder’s Birth Date: _____________________________ Employer: ______________________________________________________________________________________________________ Employer’s Address: ______________________________________________________________________________________________ Insurance Company: ______________________________________________ Group Number:__________________________________ Insurance Company Address: _______________________________________________________________________________________

If the Patient has Secondary Dental Insurance, please complete this section:Policy Holder’s Name: ___________________________________ Patient’s Relationship to the Policy Holder: _______________________ Policy Holder’s SSN: _____________________________________ Policy Holder’s Birth Date: _____________________________ Employer: ______________________________________________________________________________________________________ Employer’s Address: ______________________________________________________________________________________________ Insurance Company: ______________________________________________ Group Number:__________________________________ Insurance Company Address: _______________________________________________________________________________________

MONTGOMERY DENTAL ARTS

Medical 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 a medication that you are taking could have an important relationship with the dentistry you will receive. Thank you for answering the following questions:

Primary Physician: ____________________________ Phone: ______________________ Approximate date of last visit: ___________Are you under the care of a medical specialist? Yes / No If Yes, please list: Specialist Name: _____________________________ Phone: _____________________________Specialist Name: _____________________________ Phone: _____________________________Have you ever had an operation? Yes / NoIf Yes, please list any complications such as bleeding, infection, poor healing, etc.: _________________________________________

Are you allergic to any of the following? No Drug Allergies □ Aspirin NSAIDS Penicillin Codeine Local Anesthetics Acrylic Metal Latex Sulfa Drugs Other

If you circled any of the above, what were your symptoms when you had a reaction? ______________________________________

Have you ever taken any medications such as Fosamax, Boniva, Actonel or any other medications containing bisphosphonates for a bone condition? Yes / No If Yes, was the medication a ( ) Pill/tablet ( ) IV/injection ? How many years did you receive the medication? _______ Name of medication(s) :_______________________________________________________________________________________________

Dental History

Reasons for today’s visit: __________________________________________________________________________________________ Date of last dental care: _____________________________ Date of last dental xrays: ________________________________________ Former Dentist: ____________________________________ Address:_____________________________________________________ Would you like for your records to be sent to our office? Yes / No

Have you had a negative experience with dental treatment at any point in the past? Yes / No If Yes, please explain:_______________________________________________________________________________________________________________Do you grind your teeth or has anyone ever told you that you grind your teeth? Yes / No If Yes, please explain: _______________________________________________________________________________________________________________Do you fall asleep easily through the day, are overtired or do not feel rested? Yes / No If Yes, please explain: _______________________________________________________________________________________________________________Do you have any specific goals for your future dental treatment (for example: interest in implants, veneers, etc.) Yes / No Please explain:_______________________________________________________________________________________________________________

Have you ever been sedated for a medical procedure? Yes / No If Yes, please list any complications related to your sedation:_____________________________________________Can you easily move your head and neck in all directions? Yes / No If No, please explain:_____________________________________________

Do you use tobacco? Yes / No If Yes, what type? ____________ How long? ____________ Interested in quitting? Yes / NoDo you use controlled substances? Yes / No What type? ___________________________________ Women- Are you: Pregnant/trying to get pregnant? Yes / No If yes, when is your due date? ________________________ Taking oral contraceptives? Yes / No Nursing? Yes / No

Comments:

Medical History (p.2)

MONTGOMERY DENTAL ARTS

Do you have, or have you had, any of the following?Cortisone MedicineDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingExcessive ThirstFainting Spells/DizzinessFrequent CoughFrequent DiarrheaFrequent HeadachesGenital HerpesGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart Pace MakerHeart Trouble/Disease

AIDS/HIV PositiveAlzheimer's DiseaseAnaphylaxis

Arthritis/GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood TransfusionBreathing ProblemBruise EasilyCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DisorderConvulsions

HemophiliaHepatitis AHepatitis B or CHerpesHigh Blood PressureHives or RashHypoglycemiaIrregular HeartbeatKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve ProlapsePain in Jaw JointsParathyroid DiseasePsychiatric CareRadiation TreatmentsRecent Weight Loss

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

AnemiaAngina

If yes, please explain:Yes NoHave you ever had any serious illness not listed above?

Renal DialysisRheumatic FeverRheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSpina BifidaStomach/Intestinal DiseaseStrokeSwelling of LimbsThyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersVenereal DiseaseYellow Jaundice

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No



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 _________________________________________________________DATE ______________________

MONTGOMERY DENTAL ARTSDR. CARL SHAMBURGER • DR. DOMINIQUE ASKEW SHAMBURGER

10650 Chantilly Parkway, Montgomery, Alabama 36117 • Phone 334.356.0228 • Fax 334.356.0264www.MontgomeryDentalArts.com

If you are taking any medications, please complete this section. Please include supplements or over-the-counter medications.

Medication List

Medication Dose When I take it/How often Other Instructions

□ I am not currently taking any medications.

10650 Chantilly Parkway, Montgomery, Alabama 36117 • Phone 334.356.0228

PATIENT AGREEMENT

We are committed to providing you with the best possible care. In order to achieve these goals, we ask for your assistance and understanding of our financial and scheduling policies. Financial Policy

Payment for services rendered is due and payable at the time of treatment. We accept Cash, Checks, Visa, MasterCard, American Express and Discover.

We are an authorized provider for CareCredit® and Lending Club® patient financing, which may afford you the opportunity to make monthly payments for your treatment. Third party financing offers low interest and long term payment plans to qualified applicants. Please inquire if you are interested in applying.

Minor Children: The parent or guardian that brings a minor child in for treatment in our practice is responsible for payment for services.

Administrative Fees and Interest: There is a $30 service charge for returned checks. Account balances that are 30 days or more past due are subject to 1½% monthly interest (18% annual percentage rate (APR)).

Dental Insurance:

Dental insurance amounts are estimated coverage only; the estimated patient share of fees is required at the time of service. The patient/responsible guardian is responsible for amounts not covered by insurance or claims not paid within 60 days from date of service. Balances owed are subject to interest and collection practices of this office.

Secondary Dental Insurance Coverage: While we do file claims with secondary insurance plans, due to co-insurance limitations, any financial arrangements made in our practice will be based on estimated primary coverage only.

If you have any questions about the above information or any uncertainty regarding insurance coverage, please don’t hesitate to ask us. We are here to help!

Appointment Policy:

We do not double-book appointments in our office and request 2 business days’ notice for all cancellations of appointments. Broken appointments or late cancellations of appointments with less than 24 hours notice are subject to a $50 fee.

We ask for your cooperation in managing your appointments so that we can maintain the greatest possible access to care for each of our valued patients.

Acknowledgement: I have been informed of Montgomery Dental Arts financial and appointment policies. I agree to be responsible for all fees incurred during the course of my treatment. I hereby authorize payment of the insurance benefits otherwise payable to me directly to Montgomery Dental Arts. Agreement to Pay: I, the undersigned, accept the fee charged as a legal and lawful debt and agree to pay said fee, including any/all collection agency fees, (33.33%), attorney fees and/or court costs, if such be necessary. _________________________________________________________ _____________________________ Signature Date Express Prior Consent to Contact Consumer by Cell Phone: You agree, in order for us to service your account or to collect monies you may owe, Montgomery Dental Arts and/or our agents may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or emails, using any email address you provide to use. Methods of contact may include using pre-recorded/artificial voice messages and/or use of automatic dialing device, as applicable. I/We have read this disclosure and agree that Montgomery Dental Arts, its employees and/or agents may contact me/us as described above. _________________________________________________________ _____________________________ Signature of Patient or Responsible Party Date

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Montgomery Dental Arts

* You may refuse to sign this acknowledgement*

Name: ___________________________________________

DOB: ___________________________________________

Social Security #: __________________________________

I authorize the following for reminders of my appointments:

Open Correspondence

Messages at work Wk# _____________________________

Messages on Cell Cell# _____________________________

Text Messages Cell# _____________________________

Messages at home Hm# _____________________________

Email Email _____________________________

Postcard Address ____________________________ ____________________________

I authorize person(s) to whom my medical and dental information may be released:

______________________________ ________________________ ______________________Name Relationship Contact#



I have read the consent of this authorization form and I agree with all statements made. I understand that, by signing this form, I am confirming my authorization for use and/or disclosure of the protected health information described in this form with the people and/organizations named in this form.

I acknowledge receipt of the Notice of Privacy Practices form which details how Protected Health Information may be used and disclosed, and how I may access that information.

X______________________________________________________ ______________________ Sigature of Patient (Guardian) Date

X______________________________________________________ ______________________ Sigature of Patient (Guardian) Date

10650 Chantilly Parkway, Montgomery, Alabama 36117 • Phone 334.356.0228 www.MontgomeryDentalArts.com

Most dental insurance plans are a business arrangement between an insurance company and an employer.

It is important to remember that reimbursement and benefit levels are based on carrier and employer

business decisions and not on an individual’s need for treatment.

Dental plans are set up to pay only a portion of your dental health expenses. Dental plan maximum benefits

average $1,000 to $1,500 per year. These amounts have not changed since the 1980's, while the cost of

living has increased dramatically in comparison.

Most dental plans exclude coverage for cosmetic treatments such as teeth whitening or veneers. Many

have age or frequency limitations such as fluoride treatments or dental sealants.

Some dental plans do not offer coverage for pre-existing conditions such as missing teeth. This type of plan

would not cover prosthetic tooth replacement procedures such as bridges, partial dentures, full dentures

or dental implants. Most dental plans also have waiting periods for replacement of existing crowns, bridges

or dentures.

Many insurance plans will apply “alternate benefits” towards a service, such as paying for silver fillings

rather than tooth-colored fillings, or not covering major restorative services, such as crowns, inlays or

onlays and paying for regular fillings instead.

Some dental plans may use the terms "usual, customary and reasonable" (UCR) to determine insurance

benefits. This term applies to fee research methods used by dental insurance carriers to set reimbursement

levels across the country. The criteria upon which this research is based, such as region, time intervals, type

of dentist, etc. can vary greatly from one insurance carrier to another.

Our Commitment is to Your Health, regardless of insurance status.

Acknowledged:

I have read these Facts About Dental Insurance and I understand that any insurance reimbursement amount presented to me regarding my

dental insurance coverage is an estimate only and not a guarantee of payment. I understand that I will be given a copy of my treatment

plan with American Dental Association® (ADA) codes so that I may call my insurance company for details about my plan.

____________________________________________ ___________________________

Patient/Guarantor Signature Date

patient registration montgomery dental arts · 2020-03-17 · dental insurance amounts are...

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