acknowledgement of receipt of notice of missed · pdf fileacknowledgement of receipt of notice...

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Acknowledgement of Receipt of Notice of Missed Appointment Policy

We make every effort to value your time and we schedule your appointment time just for you.

We truly appreciate your courtesy of giving us 48 hours notice if you have a conflict with your appointment and need to schedule a different day or time. We are committed to your oral health. Keeping your scheduled appointments allows us to be partners in your dental care.

It is our philosophy to continue to put our patients first and to make your experience a positive one. Thank-you for allowing us to share our missed appointment policy with you. Please let us know if you have any questions.

I, , have received a copy of this office's Notice of Missed Appointment Policy.

Signature. _

Date _

IF YOU HAVE DENTAL BENEFITS HERE ARE SOME THINGS YOU SHOULD KNOW!

Here at Dr. Stoller's office, we believe that you deserve the best care. That's why we always present you with the best dental solution possible to treat your personal situation. Each year we provide outstanding dental care to hundreds of folks. Some have dental benefits; if you have dental benefits, Congratulations! You are very fortunate. Here are some important things you should know ...

• Your dental benefits are based upon a contract made between your employer and an insurance company. IF YOU HAVE ANY QUESTIONS REGARDING YOUR DENTAL BENEFITS PLEASE CONTACT YOUR EMPLOYER OR YOUR INSURANCE COMPANY DIRECTLY.

• Dental benefits differ greatly from medical benefits. In 1959, most dental benefit plans had a yearly maximum cap of$l,OOO.OO. You'll be surprised to know today that the average dental benefit plan has a yearly maximum cap of$l,OOO.OO. THERE HAS BEEN NO SIGNIFICANT INCREASE IN THE YEARLY MAXIMUM CAP IN 40 YEARS! However, there have been significant increases in your premiums. DENTAL BENEFIT PLANS WILL NEVER PAY FOR THE COMPLETION OF YOUR DENTAL CARE. IT IS ONLY MEANT TO ASSIST YOu.

• Many people receive notification from their insurance company that dental fees are "above usual and customary." An insurance company determines their reimbursement level by surveying a geographical area, calculating the average fee, then determines that 80% of the average fee is customary. Included in this survey are the discount dental clinics and the managed care facilities, which have severely reduced dental fees that bring down the average. ANY DOCTOR IN PRIVATE PRACTICE WILL HAVE FEES THAT INSURANCE COMPANIES DEFINE AS "HIGHER THAN USUAL AND CUSTOMARY."

• Many dental benefit plans tell their participants that they will be covered "up to 80% or 100%" but do not clearly specify the plan fee schedule allowance, annual maximum or limitations. It is more realistic to expect dental benefit plans to cover between 25% to 40% of dental services. REMEMBER THAT THE AMOUNT A PLAN REIMBURSES IS DETERMINED BY HOW MUCH YOUR EMPLOYER HAS PAID FOR YOUR DENTAL PLAN. You will get back only what your employer has put in, less the insurance company's profit margins.

• INSURANCE COMPANIES DO NOT COVER MANY ROUTINE AND NEWER DENTAL SERVICES.

Our team members will gladly assist you in filling out the necessary forms to maximize your dental benefits and discuss your financial options. Excellent dental care is available with or without dental benefits. We hope you will choose the best dentistry has to offer.

Terrill L. Stoller D.D.S. Cosmetic and Farnily Dentistry

Terrill L. Stoller D.D.S. Cosmetic and Family Dentistry

Welcome to our office. We are honored that you have chosen us as your dental healthcare provider. We are committed to providing you with the best possible care! If you have dental insurance, we will help you receive your maximum allowable benefits. In order to achieve these goals we need your assistance and your understanding of our payment policy. Payment is due at the time services are rendered unless other payment arrangements have been approved in advance by our staff. We ask that your first appointment with our office be paid in full. If you have dental insurance we will be happy to file and have your insurance company reimburse you. Fees quoted are accepted for 90 days. In the event that clinical conditions warrant a different treatment, you will be notified of changes in fees prior to proceeding with the procedure.

PATIENT FINANCIAL OPTIONS

CASH OR CHECK RECEIVE A 5% ACCOUNTING COURTESY BY PAYING IN FULL AT THE TIME OF SERVICE. For services requiring more than one appointment, to receive the 5% accounting courtesy, the entire treatment must be paid in advance at the first visit.

MASTERCARD, VISA OR DISCOVER RECEIVE A 3% ACCOUNTING COURTESY BY PAYING IN FULL AT THE TIME OF SERVICE. We accept these major credit cards to allow you the most convenience in taking care of your account.

INSURANCE The process of utilization and quality of insurance has changed much over the years. We do our best to help you understand and utilize your benefits. The amount of coverage your insurance provides is strictly a function of the policy selected by you and your employer. We will be happy to file your claim forms for you and we will accept assignment of insurance benefits on primary coverage. If you choose to assign your dental benefits to our office, we will estimate the amount not covered by your carrier and that amount will be due at the time of service (choosing this option negates the accounting courtesy). Any balance remaining after insurance payment will be your responsibility and will be due in full upon receipt of statement. Please be aware that certain carriers will not allow you to assign your benefits to our office and you will have to choose an alternative payment option.

Note: Your insurance is a contract between you, your employer and the insurance carrier. We are not a party to that contract. Ifyou have a problem with your insurance coverage, we ask that you speak directly to your insurance company. Your charges in our office are your responsibility from the date the services are rendered. We do not base your diagnosed treatment on your insurance coverage. We base it on your needs and desires. We take pride in the quality care we offer our patients and make every effort to have your dental visits with us be as comfortable as possible.

PATIENT CREDIT PLAN OR CARECREDIT (OUTSIDE FINANCING) FOR THOSE PATIENTS WHO PREFER TO PAY A LITTLE EACH MONTH. We've made special arrangements to allow you to complete your treatment with comfortable monthly payments. One of our team members will be happy to assist you and explain how the programs work. We have interest free programs ranging from 3-12 months depending on the amount financed.

GRADUAL TREATMENT PLAN FOR THOSE PATIENTS ON A LIMITED BUDGET. By prioritizing treatment, those patients who do not have dental benefits and are on a tight budget can still complete their dental work by spreading appointments over several months or years.

In the event that full payment is not made on open account balances after a reasonable period of time, our attorney will be advised and formal action to collect will be initiated. You will be responsible for any attorney's fees and/or collection charges incurred.

Thank you for reviewing our financial policy. We make every effort to explain your cost to you and to avoid misunderstandings so that we can focus on your dental health. If you have any questions please ask. We are here to serve you.

I have read, understand and agree to abide by this policy. I have been given the opportunity to receive a copy of this document.

Signature ___________________ Date _

DATE _ EGISTRATION AND HEALTH HISTORY

NAME HOME PHONE NO SOCIAL SECURITY NO

BIRTHDATE AGE

IF THIS APPOINTMENT ADDRESS CITY STATE ZIP INO. OF YEARS

IS FOR AN ADULT, EMPLOYER POSITION HELD 80 HOW LONG BUSINESS PHONE

START HERE. BUSINESS ADDRESS CITY STATE ZIP

SINGLE

I MARRIED

I SEPARATED I DIVORCED

I WIDOWED

SPOUSE EMPLOYER POSITION HELD SOCIAL SECURITY 0

BUSINESS ADDRESS CITY STATE ZIP PHONE

NAME NICKNAME SCHOOL GRADE

IF THIS APPOINTMENT BIRTHDATE AGE HOME PHONE

IS FOR ADDRESS CITY STATE ZIP

YOUR CHILD, START HERE. FATHER'S NAME SOCIAL SECURITY NO. MOTHER'S NAME SOCIAL SECURITY NO.

IF YOUR CHILD'S NAME AND ADDRESS ARE NOT THE SAME AS YOURS, FILL IN THE ADULT SECTION ALSO,

PRJMARYfMSURANCE SECONDARY INSURANCE INSURANCE COMPANY EMPLOYEE INSURANCE COMPANY EMPLOYEE

INSURANCE GROUP NO, EMP SOCIAL SEC, NO GROUP NO EMP SOCIAL SEC NO.

PERSON FINANCiAllY RESPONSIBLE FOR ACCOUNT NAME DRIVER'S LICENSE NUMBER

ACCOUNT BANK BRANCH ACCOUNT NO.

INFORMATION EMPLOYER POSITION HELD & HOW LONG BUSINESS PHONE

BUSINESS ADDRESS CITY STATE ZIP

YOUR FORMER ADDRESS

CITY STATE ZIP

PERSON TO CONTACT FOR EMERGENcY PHONE NO

GETTING ADDRESS CITY STATE ZIP

TO KNOW CLOSEST RELATIVE NOT LIVING WITH YOU PHONE NO.

YOU ADDRESS CITY STATE ZIP

REFERRED TO US BY

REASON FOR LEAVING PREVIOUS DENTIST

I UNDERSTAND THAT WHERE APPROPRIATE, CREDIT BUREAU REPORTS MAY BE OBTAINED

SIGNATURE (PARENT'S SIGNATURE IF MINOR)

MEDICAL HISTORY

It Is Important that I know your dental and medical history. Many things have a direct bearing on your dental health. I will review the questionnaire and discuss it with you In detail. Information you give me is strictly confidential and will not be released to anyone without your wrltlen permission.

PhySician's Name _ Date of Last Physical Exam _ Address _ Phone No. _

CIRCLE

1. Are you having any pain or discomfort at this time? . YES NO

2. Do you feel very nervous about having dental treatment? . YES NO

3. Have you ever had a bad experience in the dental office? . YES NO

4. Have you been a patient in the hospital during the past two years? YES NO

5. Have you been under the care of a medical doctor during the past two years? . YES NO

6. Have you taken any medicine or drugs during the past two years? YES NO

Are you now taking any medication, drugs or pills? . YES NO If YES, .please list: _

7. Are you allergic or have you reacted adversely to any of the following medications? YES NO

Aspirin Nitrous Oxide Valium Local Anesthetic

Darvon Erythromycin Scopolamine (Novocain or Xylocaine)

Codeine Tetracycline Penicillin Sleeping Pills

Demerol Percodan Other Antibiotics (Nembutal/Seconal)

8. Are you aware of being allergic to any other medications or substance? . YES NO If YES, please list: _

9. Circle any of the following which you have had or have at present:

Heart Failure Emphysema HIV Positive

Heart Disease or Allack Cough Hepatitis A (infectious)

Angina Pectoris Tuberculosis (fB) Hepatitis B (serum)

High Blood Pressure Asthma Liver Disease

Heart Murmur Hay Fever Yellow Jaundice

Rheumatic Fever Sinus Trouble Blood Transfussion

Congenital Heart Lesions Allergies or Hives Drug Addiction

Scarlet Fever Diabetes Hemophilia

Mitro Valve Prolapse Thyroid Disease Venereal Disease (Syphilis, Gonorrhea)

Artifical Heart Valve X-Ray or Cobalt Treatment Cold Sores

Heart Pacemaker Chemotherapy (Cancer, Leukemia) Fever Blisters

Heart Surgery Arthritis Epilepsy or Seizures

Artificial Joints (Hip, Knee) Rheumatism Fainting or Dizzy Spells

Anemia Cortisone Medicine Nervousness

Stroke Glaucoma Psychiatric Treatment

Kidney Trouble Pain in Jaw Joints Sickle Cell Disease

Ulcers Cosmetic Surgery Bruise Easily

Please describe any current medical treatment, Impending operations, or any other medical or dental Information that

may possibly affect your dental treatment.

FOR WOMEN ONLY:

Are you pregnant? 0 YES 0 NO If YES, what month? _ Are you taking birth controls pills? 0 YES 0 NO

ABOVE INFORMATION IS TRUE. Patient Signature: _ Date _

CONSENT: The undersigned hereby authorizes Doctor to take radiographs, study models, photographs. or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient's dental needs. : also authorize Doctor to perform any and all forms of treatment, medication and therapy, that may be indicated in connection with (Name of Patient) and further authorize and consent that Doctor choose and employ such assistance as he deems fit. I also understand the use of anesthetic agents embodies a certain risk. I understand that responsibility for payment for Dental Services prOVided in this office for myself or my dependents is mine, due and payable at the time services are rendered.

Signature: _ Date

Relationship To Patient:

60420 U.S. 31 South South Bend, IN 46614 tel 574/291-6020 fax 574/291-6051

TERRILL QSTOLL RQ creating beautiful... healthy smiles

MISSED APPOINTMENT POLICY

We want our patients to know how much we value your business. In an effort to provide the highest quality dentistry at affordable prices, we require 2 FULL BUSINESS DAYS NOTICE for any schedule changes that you may need in the future. Our office understands that sometimes emergency situations arise and we will handle each circumstance on an individual basis. We would like our patients to understand that missed or broken appointments are hurtful in many ways. First, they delay your treatment and our ability to keep your oral health at optimum levels. Second, they may prevent another patient, who needs treatment, from getting the necessary care in a timely manner. Lastly, missed appointments increase our business expenses which ultimately results in fee increases. With this in mind we want you to be informed of our appointment policy so there are no misunderstandings in the future.

Each patient may miss one appointment due to emergency without a 48 hour notice in an 18 month period. After a second broken appointment occurs we will not pre-appoint you for any future appointments without a credit card. Your name will be placed on a short call1ist and we will call you on days when there are openings in our schedule.

A third missed appointment will result in your dismissal from our practice. We will be happy to forward your records to a dentist whose hours fit your schedule.

Thank you for your cooperation. We remain committed to your oral health.

Terrill L. Stoller, DDS

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Acknowledgement of Receipt of Notice of Missed Appointment Policy

We make every effort to value your time and we schedule your appointment time just for you.

We truly appreciate your courtesy of giving us 48 hours notice if you have a conflict with your appointment and need to schedule a different day or time. We are committed to your oral health. Keeping your scheduled appointments allows us to be partners in your dental care.

It is our philosophy to continue to put our patients first and to make your experience a positive one. Thank-you for allowing us to share our missed appointment policy with you. Please let us know if you have any questions.

I, , have received a copy of this office's Notice of Missed Appointment Policy.

Signature. _

Date _

_____TerriIlIJe Stoller~ DD.......S'- _

NOTICE F PRIVACY PRACTIC s THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND

DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY We are required by applicable federal and state law to maintain the privacy of your health Information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while It is in eHect This Notice takes effect 3-/ J'-{ /0:3 . and will remain in effect until we replace It.

We I'eserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law We reserve the righ to make the changes in our privacy practices and the new terms of our Notice eHective for all health infol'mation that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices. we will change this Notice and make the new Notice available upon request

You may request a copy of our Notice at any time. For more information about our pnvacy practices, or for additional copies of this Notice, please contact us USing the Information listed at the end of this Notice

USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you for treatment, payment. and healthcare operations For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health i formation to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your heal information in connection with our healt care operations. Healthcare operations include Quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health In'formation for treatment. payment or healthcare operations, you may give us written authorization to use your health information or to disclose It to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time Your revocation will not aHect any use or disclosures permitted by your authorization while it was in eHect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in his Notice

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or With payment for your healthcare, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member. your personal representative or another person responsible for your care, of your location, your general condition. or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures In the event of your incapacity or emergency circumstances, we will disclose heal h information based on a determination using our professional judgment disclosing only heal h information that is direcily relevant to the person's involvement In your healthcare. We will also use our professional Judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays. or other similar forms of health information

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are reqUired to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your heal h or safety or the healt or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may.disclose to authorized federal oHicials health information required for lawful intelli· gence. counterintelligence. and other national security activities. We may disclose to correctionallnstitulion or law enforcement official having lawful custody of protected health information of Inmate or patient under certain circum· stances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages. postcards. or letters)

PATIENT RIGHTS Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and slaff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $0_ for each page. $_ per hour for staff time to locate and copy your health illformatlon. and postage If you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information ill that format If you prefer. we will prepare a summary or an explanation of your health information for a fee Contact us using the information listed at the end of this Notice for a full explanation of our fee structure)

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes. other than treatment. payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14,2003. If you request this accounting more than once in a 12·month period, we may charge you a reasonable. cost·based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). .

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request

Amendment: You have the right to request that we amend your health information. (your request must be in writing. and it must explain why the information shOuld be amended) We may deny your request under certain circumstances

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e·mail), you are entitled to receive this Notice in written form.

.. __.._-- .. -------------QUESTIONS AND COMPLAINTS If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights. or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the US. Department of Health and Human Services We will provide you with the address to file your complaint with the U.S Department of Health and Human Sel-vlces upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S Department of Health and Human Services.

Contact Ofti'

Telephone: TERRILL L. STOLLER, 0.0.. $. E·mail: 60420 U.S. 31 SOUTH

SOUTH BEND, IN 46614 Address:

5 7Lj. ;;) cf I - CD 0 ~o -~--~-----------

co 2002 American Dental Association

All Righls Reserved

Reproduction and use of this torn) by dentists and their staff is permitted. Any other use. dUlJlication or distribution of this form by any other oany reqUires the prior

written aopfOval of the American Derltal Associ(jlion.

(This Form is educational only, does not constitute legall3dvice, and covers only federal, nol state. law in eHecl or proposed as of March 27,2002..SubseQuent

law changes may require Form revision.)

____Terrill L. Sto er, DDS

ACK OWLEDGEMENT OF RECEI T OF NOTICE OF PRIVACY PRACTICES

* You May Refuse to Sign This Acknowedgement*

I, __________________________' have received a copy of thiS

office's Notice of Privacy Practices

Please Print Name

Signature

Date

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

o Individual refused to sign

o Communications barriers prohibited obtaining the acknowledgement

o An emergency situation prevented us fl'Om obtaining acknowledgement

o Other (Please Specify)

to 2002 American DenIal Association

All Rights Reserved

Reproduction and use of lhis form by denllsts and their slail is oermill'::d. ~~lY other use. duplication or dislributior, Of lhis 101'01 (I~ ~nyClI1e( pan.'. {.:-T.····o?.:: ",'1:; cr'C'(

writ len approval of the American Dental Association,

(This Form is educational only, does not constitute legal adVice, and covers only federal, nol state, law in eHect or orODosed as of March 27.2002 Subsequenl law changes may require Form revision.)

acknowledgement of receipt of notice of missed · pdf fileacknowledgement of receipt of notice...

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