PATIENT FORM

Broken Appointment Policy
When a dental appointment is made in our office, a specific time is reserved for the patient to see the dentist or hygienist, and much time and preparation are provided to ensure a quality visit. Broken appointments result in a loss of valuable time that could be spent with patients in need of treatment and they are very costly to our office.

We make every effort to remind patients of their appointments including a text message, e-mail, and telephone contact a few days prior.

If you do need to cancel an appointment, 48 hours' notice (business hours) is required to prevent a broken appointment charge of $50 from being applied to your account and due immediately.

For your convenience, we do have an answering machine available if you need to Il after hours to cancel an appointment.

Thank you for your anticipated cooperation!
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First NameLast Name
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Financial Agreement
*For my convenience, this office may release my information to my insurance company, and receive payment directly from them.
*I understand that if I begin major treatment that involves lab work, I will be responsible for the fee at that time.
*If sent to collections, I agree to pay all related fees and court costs.
*Every effort will be made to help me with my insurance, but if they do not pay as expected, I will still be responsible.
*I will be responsible for insurance claims not paid within 45 days of service.
*I agree to pay finance charges of 1.5% per month (18% APR) on any balance 90 days past due.
*I will pay a $50 fee for appointments broken without 48 hours' notice.
*Treatment plans may change, and I will be responsible for the work actually done.
*I give permission for my dentist and his/her clinical team to take any necessary x-rays, photos or study models to enable complete diagnosis and treatment.

For our patients with dental insurance, our professional services are rendered to you, not to your insurance company. Therefore, you are directly responsible to us for payment of treatment. As a courtesy, we do accept the assignment of benefit payments from most insurance companies. This will reduce your immediate out-of-pocket expenditures. We will do our utmost to help you derive the maximum benefits to which you are entitled.

The insurance estimates we give you are based on limited information obtained from your insurance company. We allow 45 days for your insurance company to make payment. After this time, all inquiries or follow-ups on payments due become your responsibility.
Name

First NameLast Name
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Patient Authorization for Use and Disclosure of Protected Health
I authorize the release of any information, including the diagnosis and the records of any treatment or examination rendered to my child or me during the period of such dental care to third-party payers and/or health practitioners. I also give Johns Creek Dental Studio PC permission to discuss or release my dental records to the names listed below. If no other individuals are to receive information, please place NONE in the spaces below.

The purpose(s) is/are provided so that I can make an informed decision on whether to allow the release of the information.

The Practice will not receive payment or other remuneration from a third party in exchange for using or disclosing the PHI.

I do not have to sign this authorization in order to receive treatment from Johns Creek Dental Studio. In fact, I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to the privacy officer at:

Johns Creek Dental Studio
5455 McGinnis Village PI,
Suite 103
Alpharetta, GA 30005
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Patient's Name:
DATE:

MonthDayYear
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Name of Legal Guardian, if applicable:
Signature of Patient or Legal Guardian

Clear

Notice of Privacy Policy
I have had full opportunity to read and consider the contents of the Notice and Privacy Practices. I understand that I am giving my permission to your use and disclosure of my protected health information in order to carry out treatment, payment activities, and health care operations. I also understand that I have the right to revoke permission.
NAME:

First NameLast Name
SIGNATURE:

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DATE:

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Should be Empty:

	Yes	No
Anesthetic
Aspirin
Codeine
Ibuprofen
Iodine
Latex
Penicillin
Sulfa

	Yes	No
Asthma
Bleeding Problems
Cancer
Diabetes
Heart Murmur
Heart Trouble
High Blood Pressure
Joint Replacement
Kidney Disease
Liver Disease
Pregnancy
Psychiatric Treatment
Sinus Trouble
Stroke
Ulcers
Rheumatic Fever

PATIENT INFORMATION

PERSONAL

ADDRESS AND HOME PHONE

INSURANCE POLICY 1

INSURANCE POLICY 2

Medical History for New Patient

Broken Appointment Policy

Financial Agreement

Patient Authorization for Use and Disclosure of Protected Health

Notice of Privacy Policy