Dental Patient Registration

PARENT / GUARDIAN (Complete if patient is under 18 years old)

EMERGENCY CONTACT (In an emergency, the person listed below will be told that you are receiving care at our practice.)

By providing your household size and income, you will help us meet requirements of the federal and state grants that we receive. This enables us to continue providing care for everyone in our community.

Please enter your household size and annual gross household income in the space provided. 

Thank you for your participation.

To apply, please provide the information below for everyone in your household, and attach proof of income.

PLEASE NOTE: You must submit proof of income within 30 days from the date of service or the date on this form. We will then determine your discount, which will be in effect for one year. Please provide proof of each type of income that any member of your family receives.

These are accepted proofs of income:

• 4 weeks of current, consecutive pay or unemployment stubs
• Retirement or pension documents
• Approval letters documenting Social Security, SSI, SSDI, TANF or other public assistance.
• Court documents for child support or alimony
• Current tax return

 

The above information supplied is current and accurate to the best of my knowledge. I understand that if information provided is found to be inaccurate, any discount given may be reversed.

Greater Seacoast Community Health (including Goodwin Community Health, Families First Health Center and Lilac City Pediatrics) asks our patients to understand and agree to the information in this document. More information is available in separate documents, as noted below. If you have questions about any of this information, please ask our office staff.

General Consent for Outpatient Diagnosis, Care and Treatment

• I have voluntarily come to Families First, Goodwin Community Health or Lilac City Pediatrics seeking  medical, dental and/or behavioral health services.
• I give permission for providers at these practices to conduct examinations and tests, make referrals, and provide procedures and treatment that are needed for my diagnosis and care.
• These services may be provided in-office or by telehealth (phone or video), as agreed upon when my appointment is scheduled.
• I understand that any health treatment has potential risks and benefits. I understand that I should discuss any concerns I have regarding the potential risks and benefits of such treatment with my health care providers or my child's providers.
• I understand that Greater Seacoast Community Health provides a broad range of integrated services at multiple locations, including medical, dental, mental health, substance use disorder treatment, social work, family and other services. I understand that Greater Seacoast staff providing these different services may share information as necessary to improve the quality and continuity of my care.

Confidentiality, Privacy and Disclosure of Health Information

• Federal and state laws ensure that communication between a patient and medical providers is confidential. We cannot and will not disclose medical records to anyone else unless the patient gives us written permission to do so, or under certain legal exemptions to the laws. These exemptions include when staff members suspect abuse, neglect or exploitation of a child or incapacitated adult, or that patients might harm themselves or others. Our staff is mandated by law to report in these situations.
• Greater Seacoast is required by law to maintain the privacy of patients' health information and to provide patients with the Notice of Privacy Practices. (Information on this notice is below.)
• Greater Seacoast may share information about patients, including Protected Health Information and information about alcohol and drug use, with a referring provider and/or integrated health partner with whom Greater Seacoast has a Business Associates Agreement for the continuity of patient care. (A Business Associates agreement is a signed agreement with another business or health care provider. It requires both parties to keep patients' information confidential.)

Behavioral Health Services

• The Behavioral Health and Mental Health Providers at Greater Seacoast Community Health are part of the primary care team. Any information a patient provides to the mental health providers, including information about mental health and/or alcohol and drug use, is recorded in the electronic health record. Providers and support staff who are involved in their care, or who are required to process health information for administrative purposes, are able to access this record without authorization.
• Under New Hampshire law, minors 12 years of age or older may voluntarily submit themselves to treatment for drug dependency or other drug-related problem without the consent of a parent or guardian. Any records related to such treatment are confidential unless the minor examined or treated consents in writing.

Achieving a Strong Patient-Provider Team Partnership

We value the relationships we build with our patients. Building this partnership between you and your provider team begins with mutual trust and respect.

You can expect us to:

• treat you with courtesy and respect, both in the office and on the phone
• respect your personal, religious, and cultural beliefs
• protect your privacy and ensure your dignity
• respect your individual needs and wishes and meet them as much as we reasonably can
• work together as a team to create the best treatment plan for you
• make every effort to meet your needs in a timely way, while following our policies and procedures

We expect you to:

• treat all staff and visitors with courtesy and respect, both in the office and on the phone
• keep your voice low enough that only the person you are speaking with can hear. This also keeps your protected health information private
• do your best to follow the treatment plan that you and your health care team have created
• let the team know if you have trouble following that plan

Financial Responsibility Agreement and Assignment of Benefits

• I authorize Greater Seacoast Community Health to bill and receive payment from my insurance company for services rendered.
• I understand that I am financially responsible for all charges incurred that are not covered by my or my child's insurance company, including but not limited to deductibles and co-payments.
• I authorize the release of Personal Health Information necessary to file a claim and audit with my insurance company and assign benefits to the provider or group indicated on the claim.

Documents

Please read these three documents, which are available upon request from office staff and also at GetCommunityHealth.org/patient-info/

1. Patients Notice of Privacy and Use and Disclosure of Health Information
2. Patient Rights and Responsibilities in a Patient-Centered Medical Home
3. Financial Policy

Patient Acknowledgment

I understand the information contained in this Informed Consent document. I agree to the conditions set forth in the Informed Consent and in the other documents referenced above. Any questions I had about this consent have been answered. This consent will remain in effect unless I revoke it in writing, which I may do at any time.

Please check box next to any health conditions that you have, or have had, and write in details.

I consent to be a patient at Greater Seacoast Community Health Dental Center and agree to a radiographic and clinical examination. I also understand and consent to the following:

1. I will accurately inform the dentist of my medical history including any medications and recreational drugs that I am taking and allergies that I have. I understand that some medications can cause harmful reactions with dental anesthetics, analgesic, antibiotics or other medications.
2. During the course of treatment, I may undergo procedures in all phases of dentistry including periodontics (gum treatment and surgery), restorative dentistry, oral surgery, endodontics (root canals), fixed and removable prosthodontics (crowns, bridges and dentures), implant dentistry, temporomandibular disorder treatment, oral pathology, pediatric dentistry and radiography. I acknowledge the dentists and their associates will make every effort to explain the nature and purpose of proposed procedures and alternative options, but it is the patient’s responsibility to ask questions and elect for treatment.
3. I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination.
4. I understand that there may be complications resulting from the use of dental instruments, drugs, sedation, medicines, analgesics, anesthetics and injections that include, but are not limited to: swelling, sensitivity, bleeding , pain orinfection;numbness and tingling sensation in the lip, tongue, chin, gums, cheeks, and teeth (which is transient but may, infrequently, be permanent; reaction to injections;changes in occlusion;jaw muscle cramps and spasms;temporomandibular (jaw) difficulty; referred pain to ear, neck, and head;nausea, vomiting , allergic reactions;delayed healing; and treatment failure. The risks of complications from medications used/prescribed with general dental treatment include, but are not limited to, drowsiness, lack of awareness and coordination, nauseaallergic reasons, etc. (which may be influenced by the use of alcohol, tranquilizers, sedatives or other drugs).
5. In the event that a patient requests only a specific problem be addressed (i.e.: broken tooth, pain in one area, etc.) this is considered a problem focused evaluation. X-rays will be taken in this specific area only, and a complete comprehensive exam will not be done. The dentist cannot diagnose problems in other areas of the mouth. Any future treatment of other areas will require additional x-rays and a complete exam. I understand that I will not be considered a patient of record unless this examination is completed.
6. General dentists perform the majority of all dental treatment. However, I understand that Goodwin Community Health desires that all patients should be aware that specialty fields exist in dentistry, particularly in the fields of oral surgery, orthodontics, periodontics, pediatric dentistry and endodontics. In some cases Goodwin Community Health Dental Center may have to refer certain procedures out to a specialist.
7. I am welcome to ask questions about any aspects of my dental care and will request information if I am confused or need more information. I am responsible for clarifying any aspects of my treatment that I am unsure about.

I understand that dentistry is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment that I have requested and authorized. I have had the opportunity to read this form and ask questions. My questions have been answered to my satisfaction. I am signing below that I have read and understood this form.

I authorize Greater Seacoast Community Health to obtain the patient's personal health information from the following facility or person for the purpose of transferring care.

Please INITIAL all types of information that you authorize us to release or obtain:

Methods of Disclosure Authorized: Faxed, written, phone conversation, in-person and/or secure e-mail.

• I understand that I may revoke (withdraw) this authorization at any time by notifying the practice in writing. Revocation will be effective as of date received.
• I understand that a revocation will not apply to: 1)any actions that this practice has already taken while relying on this authorization before I revoke it; or 2)  if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right
• I understand that I might be denied services if I refuse to consent to disclosure for purposes of treatment, payment, or health care operations , if permitted by state law. I will not be denied services if I refuse to consent to disclosure for other purposes.
• I  understand that the recipient of some information disclosed under this authorization may re-disclose this information and that the information will no longer be protected by federal privacy regulations.
• I understand that I have the right to: 1) Inspect or copy the protected heath information to be used or disclosed as permitted under Federal law; 2) Refuse to sign this authorization.
• This authorization will remain in effect for one year and may be revoked at any time by notifying this practice in writing.
• Unless otherwise noted, only the past two years of electronic records as stipulated above will be sent.

Patients are financially responsible for services provided by our office. Greater Seacoast participates with a number of insurance companies and will bill to all insurances.

For your convenience, our office will try to verify your insurance benefits for you. However, ultimately it is the patient’s responsibility to determine benefit and authorization information with your insurance company before services are provided. Please note that verification of benefits is not a guarantee of payment. Your insurance company makes the final determination.

Patients are fully responsible for payment for services not covered by their insurance.

Greater Seacoast strongly recommends that you have us submit a pre-treatment estimate to your insurance company before services are provided. Without this, we can only estimate your portion of the visit. Due to insurance companies’ limitations on the frequency of services, waiting periods, and maximum allowable charges, there is a chance your services may not be covered if a pre-treatment estimate is not submitted before services are rendered.

Please sign below that you have read and understand the above statement