New patient forms - Fishman Pediatric Dentistry

New Patient Information

Date*

Patient Name*

First Last

Nickname

Address

Street Address City State / Province / Region ZIP / Postal Code

Sex

DOB*

Patient Name

First Last

Nickname

Sex

DOB

Patient Name

First Last

Nickname

Sex

DOB

Patient Name

First Last

Nickname

Sex

DOB

Mother's Name

First Last

Status

SS#

DOB

Cell #

Email address

Employer

Work #

Father's Name

First Last

Status

SS#

DOB

Cell #

Email address

Employer

Work #

Emergency Contact Name (Other than Parent/Guardian)

First Last

Relationship to Patient

Emergency Contact Address

Emergency Contact Phone

Medical History Form

DOB*

Is your child under the care of another physician/specialist?

Yes
No

Name of other physician/specialist:

Reason for seeing other physician/specialist:

Is your child receiving any medication?*

Yes
No

List medication(s):

Is your child allergic to LATEX?*

Yes
No

Other allergies:*

Has your child been hospitalized, surgeries or illness?*

Yes
No

Hospitalization details:

Has your child had a history of any of the following?

Heart Trouble, heart murmur, or heart surgery*

Yes
No

Rheumatic fever or scarlet fever*

Yes
No

Asthma, TB, or lung/breathing problems*

Yes
No

HIV or AIDS*

Yes
No

Hemophilia, Sickle Cell anemia, or any other blood disorders/problems*

Yes
No

Hepatitis or liver problems*

Yes
No

Kidney infections*

Yes
No

Diabetes*

Yes
No

Congenital birth defects*

Yes
No

Cleft lip or palate*

Yes
No

Cancer, tumor or leukemia*

Yes
No

Epilepsy/seizures*

Yes
No

Autism Delay/Cerebral palsy*

Yes
No

Thyroid or glandular problems*

Yes
No

Please list any history that may not be on the list above:

DENTAL HISTORY

When and where was your child's last dental visit?

Did your child have x-rays done?

Yes
No

Was any treatment recommended?*

Yes
No

Treatment recommended:

Have there been any injuries to your child's teeth in the past (chips, fractures, etc)?*

Yes
No

List injuries:

Were there any teeth extracted/missing?*

Yes
No

List extracted/missing teeth details:

Does your child have any other siblings seen by us?*

Yes
No

List sibling(s):

Is there any additional information we should know to ensure a positive experience at our office?

CONSENT

I understand that the information I have given is correct and to the best of my knowledge, and that it will be held in the strictest of confidence. Because my child is a minor, it is necessary that signed permission be obtained from a parent or legal guardian before any dental services can be rendered. I give my consent to Dr. Fishman and his staff to perform such treatment, services, medication, local anesthesia and/or analgesia necessary to treat any dental/oral abnormality and/or infections.

Parent/Guardian Signature

Date*

Consent and Cancellations

Consent

I hereby grant authority to Dr. Fishman and his legally qualified auxiliaries to utilize x-rays, anesthetics, pre-medications, preventive and restorative procedures as may be necessary or advisable in the diagnosis and treatment of my child’s dental condition. I understand that I will be consulted before any treatment is rendered.

Parent's Signature*

Date*

Cancellations

I understand that a minimum of 24-hour notice is required to cancel or change a dental appointment. I also understand that a $60.00 broken appointment fee will be applied to my account if the cancellation occurs without a 24-hour notice. I agree to remit the fee within one week, and no further appointments will be rescheduled until the balance is cleared. I also recognize that our office will consider waiving the fee if the broken appointment is a result of a sickness.

Parent's Signature*

Date*

X-ray and Fluoride Consent

X-Ray Consent

It is recommended that children have check-up (bitewing) x-rays at each 6 months recall appointment. This is required so that the doctor is able to diagnose any new decay in your child’s mouth since their last visit. The policy holder is responsible for outstanding balance if insurance does not cover additional set of x-rays.

Select One*

I want to be aware of any possible changes in the health of my child’s teeth and would like x-rays taken every six months.
I only want x-rays taken once a year. I understand that decay may be present that cannot be detected, which may result in more extensive fillings or crowns being required after their appointment.
I do not want x-rays taken at all. I understand that the dentist will not be able to fully examine my child. I release Fishman Pediatrics from any responsibility for any condition which may be present in my child's mouth that remains undiagnosed as a result of my request that no dental radiographs be taken.

Fluoride Consent

It is the policy of the doctor to apply a fluoride application to your child’s teeth at each six months recall appointment. This is required to help prevent the chance of decay. Some insurance companies allow for fluoride at each of their recall appointments , while others have a frequency limitation, only paying for fluoride once a year.
Note: The policy holder is responsible for any balance if insurance does not cover additional Fluoride treatment.

Select One*

I want fluoride applied to my child’s teeth at every six months.
I only want fluoride once a year. I am aware that the lack of fluoride may help to promote tooth decay.

Parent's Signature*

Date*

Insurance Agreement

Do you plan to use dental insurance?*

Yes
No

Ross H. Fishman, DMD
Board Certified Pediatric Dentistry
Practice Limited to Children and Teens

To the Parents of our Patients,

Please read the following information. It will be necessary for you to sign this statement before we agree to accept assignment of payment from your insurance company. We desire to avoid any misunderstanding as a result of the increasingly complicated process of arranging payments.

Please be aware that many insurance companies are undergoing significant changes that complicate reimbursement and produce difficulties for you and your health care providers. Should repeated insurance submissions be required, there may be additional administrative charges to your account.

Filing your insurance is a time-consuming task. It is a courtesy service performed by this office which we hope to be able to continue to offer you.

Should you have any questions, please feel free to speak with our office staff.

OFFICE INSURANCE POLICY AGREEMENT

Current Dental Insurance Company:*

Policy Holder's Name*

First Last

Employer*

Subscriber ID*

Policy Holder's DOB:*

This is the date of birth of the policy holder.

Please indicate your understanding of the following:

I understand that it is my responsibility to provide Fishman Pediatric Dentistry with the correct insurance information.*

I understand

I understand that I am responsible for any balance on my account as a result of my insurance company's failure to make a payment on an insurance claim.*

I understand

I understand that often insurance plans change on a yearly basis and that it is my responsibility to alert Fishman Pediatric Dentistry of any changes regarding my insurance.*

I understand

INSURANCE AGREEMENT

I understand and agree that I am personally responsible for the payment of all examination and treatment fees on my account. If my insurance company fails to make prompt payment, or denies payment for any reason, I will be responsible to make payment for the full amount without delay.

I understand and agree that I am responsible for the estimated amount not paid by my insurance company. This portion, plus the deductible, is due at the time of the appointment, when examination or treatment is rendered. I understand that after my insurance company makes payment, there may still be a balance remaining, for which I am responsible.

I have been informed if I hold a PPO insurance, I am responsible for amounts due after insurance pays. I am aware my insurance may be OUT OF NETWORK, resulting in my out of pocket being my responsibility. The staff has informed me OUT OF NETWORK policies and procedures.

Parent signature*

Date*

Introduction

Thanks for bringing your child to our office. We consider it a privilege for our team to have the opportunity of providing you with the best dental care possible in a child friendly environment.

All of the members of our team have had years of experience treating children. Every child, though, is different. If you have some special thoughts or questions about your child, please feel free to let us know.

It is part of our practice philosophy to allow parents to be with their child in the operatory before or during treatment. This allows for increased understanding of your child’s dental needs and the means necessary to provide that care.

We will make every effort to keep our appointments on schedule. Challenges to that commitment occur on a daily basis as some children require additional attention based on their own individual background of experience.

We want to be fair to all of our patients. We ask that you work with us in scheduling your child’s appointment. If you have had a morning appointment you will have the option of an afternoon appointment for your next scheduled visit.

Payment is expected when services are rendered and can be made by cash, check or credit card. There will be a $20 charge for any returned checks. If an account becomes delinquent for more than 90 days, it may be referred to an outside collection agency. You will be responsible for any additional fees associated with the collection process, including attorney fees and court cost.

Should you have dental insurance, please check with our front office staff. We do not accept all insurance policies. Most insurance policies will only cover a portion of the fees. You will be responsible to pay your portion on the day that services are rendered. If we do not accept your policy, we will provide you with a receipt for services rendered for you to attach to the claim form provided by your insurance carrier. Insurance companies requiring multiple claims for payment may result in an insurance filing fee added to your statement balance.

Failure to give 24-hour notice may result in a broken appointment fee being added to your account balance.

Signature*

Date*

Notice of Privacy Policy

Fishman Pediatric Dentistry

As a patient at this office, the doctor and assistants will obtain information about you and record it in a health record with your consent. The practice is permitted by Federal Privacy Laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected Health Information is the information we create and obtain in providing our services to you.

Some examples of information collected in our office include:

Information you provide on our patient history and information forms.

Medical and health information you authorize us to receive from doctors and other health service providers.

How we use and disclose your information

The primary use of your information is to verify your identity in the course of service provided to you.

During the course of your treatment it may be necessary to speak with other doctors and share information to obtain their input.
If we submit a request for payment to your insurance carrier, the insurance company may request information from us regarding medical care given. We will provide information to them about you and the care given.
We obtain services from the insurances and our other business associates such as quality assessments, quality credentialing, medical review, legal issues and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services.

Your Health Information Rights

The health record we maintain, and billing records are the physical property of the practice. The information in it, however, belongs to you. It is your right to:

Request a restriction on certain issues and disclosures of your health information by delivering the request in writing to this office. However, we are not required to agree with your request.
Request that you be allowed to inspect and copy your health record and billing information by delivering your request in writing to this office. We may deny this request in certain instances. If we deny a request for any reason you have the right to have our denial reviewed. Our office is permitted to charge a reasonable fee for copying and mailing the protected health information.
Request that your health record be amended to correct incomplete information by delivering a written request to our office. You may file a statement of disagreement if your amendment is denied and required that the request of amendment and any denial be attached in all future disclosures of your protected health information.
Request an accounting of disclosures of protected health information made by this office by submitting a written request to this office. An accounting will not include internal uses of information for treatment, payment, operations, disclosures made to you or at your request, or disclosures to family members or friends in the course of providing care.

If you wish to exercise any of the above rights, please contact Gina Fishman, Office Manager, 552 Jacksonville Dr. Jacksonville, FL 32250 by letter or in person during normal business hours. You will be provided with assistance on the steps to take to exercise your rights. If you believe that your privacy rights have been violated, you may file a complaint at our office by delivering a written letter of complaint to this office. You may also file a complaint by mailing it to the Secretary of Health and Human Services. We cannot and will not require you to waive your rights to file a complaint as a condition of receiving treatment or retaliate against you for filing a complaint with the Secretary.

Unless you object, we may use or disclose to you protected health information to notify, or assist in notifying a family member, personal representative, or other person responsible for your care, about your location and about your general condition.

Signature*

Date*

Request a copy?*

Yes
No

Email*