ludi crownover - cheneweth shelly · ludi crownover ludi crownover patient coordinator . 236...
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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
236 Hospital Dr. Suite A, Ukiah CA 95482 / phone 707.468.0444 / www.beautifulsmilesofukiah.com
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.
236 Hospital Dr. Suite A, Ukiah CA 95482 / phone 707.468.0444 / www.beautifulsmilesofukiah.com
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.
236 Hospital Dr. Suite A, Ukiah CA 95482 / phone 707.468.0444 / www.beautifulsmilesofukiah.com
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
236 Hospital Dr. Suite A, Ukiah CA 95482 / phone 707.468.0444 / www.beautifulsmilesofukiah.com
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
236 Hospital Dr. Suite A, Ukiah CA 95482 / phone 707.468.0444 / www.beautifulsmilesofukiah.com
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
Please see reverse side.
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: ________________________________________________
236 Hospital Dr. Suite A, Ukiah CA 95482 / phone 707.468.0444 / www.beautifulsmilesofukiah.com
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.
Please see reverse side.
236 Hospital Dr. Suite A, Ukiah CA 95482 / phone 707.468.0444 / www.beautifulsmilesofukiah.com
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