Patient Information

Please take a moment to enter or update your information to help us ensure the quality of your care is excellent.

Chart#:

Patient Name:

Title:

Gender:

Male Female

Family Status:

Married Single Child Other

Birth Date:

SS#:

Prev. Visit:

Email Address:

Best time to call:

Phone:

Address:

Whom may we thank for referring you to our practice?

Dental Office Yellow Pages Internet Newspaper Work OTHER

Name:

APPOINTMENT CHANGES: We are committed to providing excellent dental care to all of our guests. We DO NOT overbook our patients. This appointment time is reserved solely for you/your care. Last minute cancellations, not coming to your scheduled appointments or showing up late will have a significant impact on our day and the service we can provide our patients. It may be necessary for us to charge you if you neglect to show up for your reserved appointment, or provide us with less than 48 hours notice if needing to rearrange your appointment.

I have been notified that Branchburg Dental requires 48 hours notice to rearrange any appointments. I understand that I will receive a call 48 hours prior to my appointment and this call serves as a reminder only. If I need to rearrange my appointment time/date, I will provide Branchburg Dental with at least 48 hours notice. If I fail to provide such notice or fail to show up for a reserved appointment

Do we have your permission to communicate with you via text messaging?

Yes No

Do we have your permission to communicate with you via email?

Yes No

Preferred Email:

Employment Information

Employer Name:

Primary Insurance Information

Primary Dental Insurance:

Name of Insured:

Insured's Birth Date:

ID #:

Group #:

Insured's Address:

Insured's Employer Name:

Employer Address:

Patient's relationship to insured:

Self Spouse Child Other

Insurance Plan Name:

Insurance Address:

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
Health Insurance Portability Accountability Act (HIPAA), 1996 http://www.hhs.gov/ocr/hipaa/finalreg.html PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting: Branchburg Dental, 1069 Route 202 North, Branchburg NJ 08876, 908-722-8110 contact@branchburgdental.com www.branchburgdental.com Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

CONSENT FOR ELECTRONIC HEALTH RECORDS:
EHRs (Electronic Health Records) are electronic versions of the paper charts in your doctor's or other health care provider's office. An EHR may include your medical history, notes, and other information about your dental/medical health including your symptoms, diagnoses, medications, lab results, vital signs, and reports from diagnostic tests such as x-rays. Providers are working with other doctors and dental/medical carriers to find ways to share that information. The information in EHRs can be shared with other organizations involved in your care if the computer systems are set up to talk to each other. Information in these records should only be shared for purposes authorized by law or by you. You have privacy rights whether your information is stored as a paper record or stored in an electronic form. The same federal laws that already protect your health information also apply to information in EHRs. EHRs will be used to submit all your dental claims. You have the right to request all claims not be sent by electronic methods. If your choice is to have paper claims submitted, you will be provided with a paper claim which you can submit on your own behalf, as our office submits all claims electronically. Our office is fully complaint with electronic encryption and all records sent electronically are sent in a secure method.

I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and health care operations. Acknowledgement of Receipt Notice of Privacy Practices Purpose: This form is used to obtain acknowledgement that you have been notified that our NOTICE OF PRACTICE POLICIES can be obtained via our office. This document is printable via the web site for your records.
HIPAA web-site: http://www.hhs.gov/ocr/hipaa/finalreg.htm
You May Refuse to Sign This Acknowledgement of this offices Notice of Privacy Practices.

Signature of patient, parent, or guardian (responsible party):

Date

Consent for Services

As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined befor treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for at the time services are performed.

Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. Branchburg Dental will help prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any payments to the patient's account. However, Branchburg Dental cannot render services on the assumption that our charges will be paid in full by an insurance company.

A service charge of 1½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.

I understand that any fee estimate for my dental care can only be extended for a period of six months from the date of my examination.

In consideration for the professional services rendered to me by Branchburg Dental, I agree to pay the charges for the services at the time of treatment, or within fifteen days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suits be instituted hereunder.

I grant my permission to Branchburg Dental to telephone me to discuss financial arrangements or my treatment.

I have read the above conditions of treatment and payment and agree to their content. I authorize Branchburg Dental to submit my dental claims and I assign dental benefits to be paid to their office. I assume responsibility for all treatment rendered to me by Branchburg Dental.

Signature of patient, parent, or guardian (responsible party):

Date

TO MAKE AN APPOINTMENT:

CALL US AT 908-722-8110
EMAIL US AT CONTACT@BRANCHBURGDENTAL.COM
OR STOP IN AT 1069 US ROUTE 202 NORTH, BRANCHBURG NJ.

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