LASER PERIODONTICS DENTAL IMPLANTS

5448 Spalding Drive, Bldg 100, Ste B ∙ Peachtree Corners, GA 30092 Phone: 770.448.3333 ∙ Fax 770.409.9422 ∙ AtlantaLaserPerio.com (1)

Medication List

If you are taking any medications, please complete this form. Please include prescription(s),

over-the-counter medication(s), vitamins and supplements.

My Name is __________________________________________________________________

My Health Care Provider’s Name is _______________________________________________

My Health Care Provider’s Phone Number is ________________________________________

I am currently taking the following prescription and over-the-counter medications, vitamins &

supplements:

Medication

When I take it

Dose

Other Instructions

___________________________________________________________ __________________

Signature of Patient or Guardian Date

5448 Spalding Drive, Bldg 100, Ste B · Peachtree Corners, GA 30092 · AtlantaLaserPerio.com

Phone 770.448.3333 Fax 770.409.9422

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES

*You May Refuse to Sign this Acknowledgement*

I, _________________________________________________________ have received or been

offered a copy of the Notice of Privacy Practices for the practice of Susan J. Baker,

D.M.D.

__________________________________________________________________________________

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:

HIPAA PRIVACY CONSENT AUTHORIZATION

Patient Name: ____________________________________________________________________

Due to strict HIPAA laws we are not allowed to share your information with anyone except

your insurance company (if applicable) and your other physicians, including but not limited

to your general dentist, other dental specialists and your medical doctors. Should you have

someone you would want us to share your information with, they must be listed below with

your relationship for our records. This authorization is valid for one year from the date signed.

You can change this authorization at any time in writing and signed by you.

Name: ___________________________________________________ Relationship: __________________

Name: ___________________________________________________ Relationship: __________________

Name: ___________________________________________________ Relationship: __________________

Name: ___________________________________________________ Relationship: __________________

__________________________________________________________ _______________________________

Patient/Guardian Signature Date

5448 Spalding Drive, Bldg 100, Ste B · Peachtree Corners, GA 30092 · AtlantaLaserPerio.com Phone 770.448.3333 Fax 770.409.9422

PATIENT FINANCIAL POLICY NOTICE

Thank you for selecting Dr. Susan J. Baker for your dental care services. We are committed to

providing the highest quality of care. As a courtesy to you, if applicable, we will bill your insurance

company for any services rendered.

You have been/will be given a Treatment Plan Estimate detailing your estimated patient financial

portion for any/all prescribed dental services. Insurance estimates are provided as a courtesy and

are based on current information collected from your insurance carrier. While we would like to

advise you what your exact financial obligation is before your date(s) of service, the scale of

different insurance plan designs make it extremely difficult. Your estimated patient portion may

vary based on actual payments made by your insurance provider. Please understand the

contract itemizing your dental benefits is between you, your employer, and your insurance

company.

Claims for your dental care are submitted on the day treatment is completed. In the event your

insurance carrier remits less than the estimated amount of the claim, for any reason inclusive of

denied claim, the patient/responsible party, is financially responsible to pay the unpaid balance.

Bills for any amount due will be sent to you upon receipt of remittance or explanation of benefits

by your insurance company. Payment is due within 10 business days from the date the bill is

mailed. If payment is not received by the noted due date, it will be considered PAST DUE and may

be subject to interest and/or collections. Any questions or arrangements pertaining to your bill

must be addressed within 10 day period to keep this account in good standing within our office.

Financial Responsibility Agreement

Dr. Susan J. Baker is committed to providing the highest quality of care and services to our patients.

In return, I agree to be financially responsible for payment of Dr. Susan J. Baker/Atlanta Laser

Periodontics & Dental Implants services. I agree to give Dr. Susan J. Baker/Atlanta Laser

Periodontics & Dental Implants complete and accurate insurance information for any

primary/secondary insurance coverage. I understand that failure to supply complete and

accurate information may result in denial of my claim or delay insurance remittance. I understand

that Dr. Baker has the right to close any unpaid claim that is older than 60 days from the date of

service. I agree to pay any balance remaining on my account after insurance claim(s) are

processed. Initial: _____

I understand my financial responsibilities as they may relate to my dental insurance plan, and

understand that any insurance portion(s) not paid by my insurance company(ies) are my financial

responsibility. In the event of self pay patients, no-insurance based treatment, I understand that I

will be given a detailed treatment and fee estimate prior to any dental work performed. I

understand that I will be financially responsible for the cost of each treatment.

Initial: _____

I acknowledge that dentistry is not an exact science and changes in treatment may become

necessary during the course of my care. I understand that I will be kept informed of any necessary

changes and acknowledge that I will be financially responsible for any such changes.

Initial: _____

SUSAN J. BAKER, DMD PATIENT AGREEMENT

5448 Spalding Drive, Bldg 100, Ste B · Peachtree Corners, GA 30092 · AtlantaLaserPerio.com Phone 770.448.3333 Fax 770.409.9422

I understand that any invoice or receipt issued by Dr. Baker is a non-binding estimate only, and

additional charges may apply depending upon actual amounts remitted by my insurance

company for services rendered. I agree to pay any balance remaining on my account within 10

days upon receipt of a statement requesting payment.

Initial: _____

Please acknowledge your understanding of this notice and your willingness to comply with the

above.

___________________________________________ _________________________________________

Print Patient Name/Date Signature of Financially Responsible Party

MISSED OR BROKEN APPOINTMENTS

Our Promise to You. I, Dr. Susan Baker and my staff will do everything within our power to make

sure that you have an incredible dental experience. You will find our staff to be friendly,

welcoming and accommodating. We do not operate a “dental clinic”, but rather an

appointment-based office that allows you to receive necessary dental treatment in a predictable

and timely manner. When an appointment is scheduled, staff members will be here to treat you

and meet your needs.

We do understand that needs change and unexpected occurrences arise from time to time. If

you have scheduled an appointment and this is the case, we ask that you contact the office as

soon as possible. You will find our staff happy to assist you and reschedule your appointment as

quickly and conveniently as our schedule allows. We require a minimum of a 48-hour notice (or 2

business days) to cancel or reschedule an appointment. Surgery appointments require a

minimum of 72 hours’ notice (or 3 business days).

Appointments that are cancelled, rescheduled or missed within 48-72 hours (or 2-3 business days)

of the scheduled appointment time are considered broken appointments and are subject to a

broken appointment fee. These fees vary based on the time allotted to the type of treatment.

Remember, a specific time has been set aside for each patient and our staff is available to

address every concern. Broken or missed appointments are unused hours within our day that

could have been offered to another patient that is waiting for treatment. Please know that we

are committed to you and your dental care needs, we hope you are just as committed.

I have read and understand the above office policy pertaining to missed, broken or rescheduled

appointments and acknowledge and agree to the terms and conditions presented.

___________________________________________ _________________________________________

Print Patient Name/Date Signature of Financially Responsible Party