• DENTAL INSURANCE

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  • ASSIGNMENT AND RELEASE

    1, the undersigned certify thal I (or my dependenl) have insurance coverage with

  • sign directly to Dr.

  • all insurance benefits, ii any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

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  • PHONE NUMBERS

  • IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)

  • DENTAL HISTORY

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  •   Yes No
    Bad breath
    Bleeding gums
    Blisters on lips or mouth
    Burning sensation on tongue
    Chew on one side of mouth
    Cigarette, pipe or cigar smoking
    Clicking or popping jaw
    Dry mouth
    Fingernail biting
    Food collection between the teeth
    Foreign objects
    Grinding teeth
    Gums swollen or tender
    Gums swollen or tender
    Lip or cheek biting
    Loose teeth or broken fillings
    Mouth breathing
    Mouth pain, brushing
    Orthodontic treatment
    Pain around ear
    Periodontal treatment
    Sensitivity to cold
    Sensitivity to heat
    Sensitivity to sweets
    Sensitivity when biting
    Sores or growths in your mouth
  • HEALTH HISTORY

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  •   Yes No
    AIDS
    Anemia
    Arthritis, Rheumatism
    Artificial Heart Valves
    Artificial Joints
    Asthma
    Back Problems
    Bleeding abnormally, with extractions or surgery
    Blood Disease
    Cancer
    Chemical Dependency
    Chemotherapy
    Circulatory Problems
    Congenital Heart Lesions
    Cortisone Treatments
    Cough, persistent or bloody
    Diabetes
    Emphysema
    Do you wear contact lenses?
    Epilepsy
    Fainting or dizziness
    Glaucoma
    Headaches
    Heart Murmur
    Heart Problems
    Hepatitis
    Herpes
    High Blood Pressure
    HIV Positive
    Jaundice
    Jaw Pain
    Kidney Disease
    Liver Disease
    Low Blood Pressure
    Mitral Valve Prolapse
    Nervous Problems
    Pacemaker
    Psychiatric Care
    Radiation Treatment
    Respiratory Disease
    Rheumatic Fever
    Scarlet Fever
    Shortness of Breath
    Sinus Trouble
    Skin Rash
    Special Diet
    Stroke
    Swelling of Feet or Ankles
    Swollen Neck Glands
    Thyroid Problems
    Tonsillitis
    Tuberculosis
    Tumor or growth on head or neck
    Ulcer
    Venereal Disease
    Weight Loss, unexplained
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  • MEDICATIONS

  • ALLERGIES


  • Patient Consent & Notice Of Privacy Practices Acknowledgement

  • I understand that, under the Health Insurance Portability & Accountability Act of 1996 ( HIPAA ) , I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

    • --Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly
    • --Obtain payment from third party payers
    • --onduct normal healthcare operations such as quality assessments and physician certifications

    - I have been informed by you of your Notice of Privacy Practices describing the uses and disclosures of my health information. I have been given the right to review such Notice Of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice Of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of Notice Of Privacy Practices.

    -I Understand that I may request in writing that you restrict how my private information is used and/or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

    -I understand that l may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

    -I hereby authorize you to use or disclose the specific information described below, only for the purposes and parties also described below.

    • Description of specific information to be used and/or disclosed: Insurance Company Name. Subscriber ID and information. treatment and treatment plan. medical history and x-rays.
    • Person or entit y requesting and receiving the information and authorized to make the requested use of disclosure: Insurance, Laboratory, Specialist and any additional authorized persons listed below.
  • This authorization shall remain in effect for 12 months from the date signed. I understand I may refuse to sign this authorization with the understanding that you may refuse to perform treatment.

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  • OFFICE USE ONLY

  • We attempted to· obtain consent in acknowledgement of this Notice Or Privacy Practices, but unable to do so for reasons documented below.

  • Sayyar Family Dentistry

    5231 Hickory Park Dr. Suite E Glen Allen VA, 23059804-290-8001


    Patient Responsibility Agreement

  • Patient Responsiblllty - Payment Is Due At Time Of Service

    We have several payment options available

    Cash

    5% discount for treatment paid in full prior to the time of treatment
    • ONLY For patients without dental insurance
    Credit All major credit cards are accepted
    Check We gladly accept your check; if your check Is dishonored or returned for any reason we will electronically debit your account for the amount of the check plus a processing fee of $45.00.
    Care Credit Please see brochure for details
    PGSPP Sayyar Smile Protection Plan, our in-house dental discount plan, please ask for details

    Appointment Policy

    • If you are late to your appointment we reserve the right to reschedule your appointment if necessary.
    • It is your responsibility to remember your appointment, as a courtesy reminder calls, emails, and text messages are sent.
    • If you must reschedule or cancel your appointment a 48 hour notice is required, messages are not an acceptable way to cancel an appointment. If you do not come to your scheduled appointment or cancel your appointment with less than 48 hours notice you may be charged a cancellation fee of $50.00 or 10% of the scheduled treatment.

  • Patient Visitors Policy

    • Patients that have an appointment are allowed one guest during the visit; the guest may remain in the waiting room while the patient is being treated in the clinical area.
    • We require that no children under the age of 12 remain in the waiting room unattended.
    • Unless child is being treated by the doctor please do not bring them in the clinical area.

    Composite Fillings

    • As a reminder, this office is amalgam free (silver filling). We only place composite fillings (white/tooth colored). Some insurance companies downgrade composite fillings and pay at a lesser rate. Therefore, the patient is responsible for the difference in payment. If you have any questions please ask the front desk and they will be happy to help.

    Private Dental Insurance

    • As a courtesy to our patients we will file your claims for dental services we provide to you. We require the patient responsibility and deductible to be paid at the time of treatment. You are responsible for providing accurate, current insurance information at each visit. Please present your insurance card at each visit. You are responsible for any remaining balance after your insurance company has processed your claim. If your insurance company does not process and pay your claim for any reason after 60 days you will be responsible for the balance.

    In consideration for services rendered to me or my dependent child, I authorized Dr. Shahareyar Sayyar and associates to bill my insurance carrier for all services provided and that all payment for services rendered will come directly to Shahreyar S. Sayyar. I give authorization to the release of any information requested by my insurance company with respect to insurance claims. I assume all responsibility for any portion of treatment cost not paid by my insurance company. I agree that if I do not have insurance or my insurance Is not active at the time of treatment, I AM RESPONSIBLE FOR PAYING IN FULL AT THE TIME OF SERVICE FOR ALL TREATMENT. If for any reason my account becomes delinquent, I agree to pay an interest rate of 1.5% p er month, or 18% annually, on balance more than 60 days old, plus any attorney's fees that may be added.

    I have read and understand the Financial, Insurance , and Patient responsibilities as noted in this authorization

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