New Patient Form




PATIENT INFORMATION:


       
Address




INSURANCE INFORMATION:

(Please give your insurance card to the receptionist.)

MINOR CHILD - May need to complete both Primary and Secondary Insurance fields for parent information.
ADULTS - Complete Primary Insured
DUAL COVERAGE - Also complete both Primary and Secondary Insurance fields.


 - SELF PAY
 - MEDICARE
 - MEDICAID

PRIMARY INSURED

(If no insurance, complete for responsible)
First Name

Middle Initial








Relationship to Patient





SECONDARY INSURED

First Name

Middle Initial








Relationship to Patient





 

PERSON TO CONTACT IN CASE OF EMERGENCY






Has any member of your family ever been treated in our office?

PHARMACY INFORMATION




HEALTH HISTORY:

7. DO YOU HAVE, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING:
 - ADD / ADHD
 - Anemia
 - Angina
 - Arthritis
 - Asthma
 - Autism Spectrum
 - Bleeding Disorder
 - Bleeding Tendency
 - Blood Transfusion
 - Bronchitis
 - Bruise Easily
 - Cardiovascular Disease
 - Cancer
 - Chest Pain
 - Chronic Cough
 - Colitis
 - Congenital Heart Disease
 - Convulsions
 - Coronary Artery Disease
 - Diabetes
 - Difficulty Opening Mouth
 - Dizziness
 - Emphysema
 - Epilepsy
 - Fainting
 - Glaucoma
 - Goiter
 - Grind/Clench Teeth
 - Heart Attack
 - Heart Murmur
 - Heart Surgery
 - Heart Valve
 - Hepatitis
 - High Blood Pressure
 - HIV/AIDS
 - Immune Suppression
 - Implant
 - Jaundice
 - Jaw Clicking/Popping
 - Joint Replacement
 - Kidney Disease
 - Liver Disease
 - Lung Disease
 - Nervous Disease
 - Pacemaker
 - Pain Near Ear
 - Pneumonia
 - Psychiatric Treatment
 - Radiation Treatment
 - Rheumatic Fever
 - Rheumatic Heart Disease
 - Seizures
 - Severe Coughing
 - Shortness of Breath
 - Sinus/Nasal Problems
 - Stomach Ulcers
 - Stroke
 - Thyroid Disease
 - Tuberculosis
 

 

 
10. Do you smoke or chew tobacco?Yes  No
       If yes, how much per day? 
11. Do you have a history of alcohol or chemical dependency that may affect the care we provide? Yes  No
12. Are there any mental health issues and/or emotional disorders that may affect the care we provide? Yes  No
13. Have you had any serious problems/complications associated with any past dental treatment? Yes  No
14. Have you or an immediate family member had any problem with IV anesthesia? Yes  No
15. Do you have any other disease or condition not listed above that you think the doctor should know about? Yes  No
16. Do you wish to talk to the doctor privately about anything? Yes  No

FEMALE PATIENTS:

A. Are you pregnant, or is there a chance you may be pregnant? Yes  No
B. Are you breastfeeding? Yes  No
C. If you are using oral contraceptives, it is important that you understand that antibiotics and some other medications may interfere with the effectiveness of oral contraceptives. Therefore, you will need to use other forms of birth control for one complete cycle of birth control pills after the course of antibiotics/medication is completed. Please consult with your physician for further guidance.  


ACKNOWLEDGEMENT


I understand the importance of an accurate, truthful health history to assist the doctor in providing the best care possible. I have had the opportunity to discuss my health history with the doctor.
 
 By checking this box, you are signing this form electronically. You agree your electronic signature or typed name on the signature line is the legal equivalent of your manual signature on this form.

 
Signature of Patient or Representative (please hold down mouse button and sign)


 





FINANCIAL POLICY

 
Welcome to our office! At Dr. Williams's office, we are proud to be a team of healthcare professionals whose goal is to provide you with the highest quality and most cost-effective care possible. We are aware that unexpected healthcare costs can significantly impact your budget ad we want to make our services as affordable as possible. In order to assist you with your healthcare investment, we ask that you read the following information regarding our available payment options. The patient (or parent/legal guardian, if the patient is a minor) is responsible for payments in full at the time our services are rendered.

INSURANCE

We will gladly estimate your deductible, your portion of treatment costs, and bill your insurance company for your treatment fees, all at no extra cost to you. The estimated amount not covered by your insurance company is due at the time the treatment is rendered. Our estimates are subject to final approval by your insurance company; therefore, YOUR EXACT PORTION OF THE TREATMENT COSTS CANNOT BE DETERMINED UNTIL WE HAVE RECEIVED THE FINAL PAYMENT FROM YOUR INSURANCE COMPANY. If you have a balance remaining after insurance pays, you will be sent a final statement at that time. We do not bill secondary insurance companies, but we will provide you with copies of the needed information so that you can forward them to your secondary insurance company for reimbursement.

Please remember that your insurance is your responsibility. While we are happy to help you with claims submission, we can make no guarantee about your insurance payment. We allow 45 days for your insurance company to make payment. After this time all inquiries and follow-up become your responsibility. No finance charges will be applied if all balances are paid in full within 90 days of date of service.
 
PRE-AUTHORIZATION OF INSURANCE BENEFITS

Pre-authorization of insurance benefits may be in your best interest. Many patients are uncertain if recommended treatment is covered by their insurance plan, or what percentage the insurance may pay for covered benefits. In some cases, insurance companies do require pre-authorization for any treatment that will be over a specific dollar amount or certain types of treatment. In these situations, we will be happy to send the required information to your insurance company for pre-authorization consideration. This process normally takes 3 to 6 weeks for insurance companies to process the paperwork and get it back to us. Emergency treatment is normally excluded from this pre-authorization process.

PAYMENT INFORMATION

Payment options: Financial options are discussed during the initial visit. Dr. Williams and his business team are committed to providing excellent care and guiding patients in selecting the best payment option for their individual needs. We accept CASH, PERSONAL CHECK, VISA, MASTERCARD, DISCOVER, and AMERICAN EXPRESS, or financing through CARE CREDIT and LENDING CLUB.

SERVICE CHARGE

If I do not pay the entire new balance within 60 days of the monthly billing date, a service charge will be added to the account for the current monthly billing period. The service charge will be a periodic rate of 1% per month. In the case of default of payment, I promise to pay any legal interest on the balance due, together with any collection costs and reasonable attorney's fee included to effect collection of this account or future outstanding accounts.

AUTHORIZATION 

I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize the Dental Office to administer such medications and perform such diagnostic, photographic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the dental histories are correct to the best of my knowledge. I grant the right to the dentist to release my dental histories and other information about my dental treatment to third party payers and/or other health professionals.

ELECTRONIC SIGNATURE AGREEMENT

 By checking this box, you are signing this form electronically. You agree your electronic signature or typed name on the signature line is the legal equivalent of your manual signature on this form.

 
 
Patient/Guardian signature (please hold down mouse button and sign)








CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

 

Section A: PATIENT GIVING CONSENT

Name:      
 

Address:  

Phone:     

SSN:        

 

Section B: PATIENT GIVING CONSENT (Please read the following statements carefully)


Purpose of Consent: By signing this form, you consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before deciding to sign this form. Our Notice provides a description of our treatment, payment activities, healthcare operation, the uses and disclosures we may make of your protected health information, and of other important matters concerning your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions to your Notice, at any time by contacting any member of Dr. Williams's team by: (phone) 303-493-1933, (fax) 303-493-1934 or by coming to our office at 14000 E. Arapahoe Rd., Ste. 320, Centennial, CO 80112.

Right to Revoke: You have the right to revoke this Consent at any time by giving us written notice of your revocation. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation and that we may decline to treat you or continue treating you if you revoke this Consent.

ACKNOWLEDGEMENT: 

I,   , have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that by signing this Consent form I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.

ELECTRONIC SIGNATURE AGREEMENT

 By checking this box, you are signing this form electronically. You agree your electronic signature or typed name on the signature line is the legal equivalent of your manual signature on this form.

 

Signature of Patient or Representative (please hold down mouse button and sign)
 











COMMUNICATION CONSENT FORM

 
Patient Name:   Date of Birth: 

 


I authorize the office of Williams Dental Implant & Oral Surgery to speak with the following individuals about my care:
 

Name:              Name:      
 

Relationship:                    Relationship:      

Phone:              Phone:      

Please be aware: if you choose to leave the above section blank, we will be unable to discuss your treatment, appointments, billing information, etc. with anyone who may call on your behalf.

ELECTRONIC SIGNATURE AGREEMENT

 By checking this box, you are signing this form electronically. You agree your electronic signature or typed name on the signature line is the legal equivalent of your manual signature on this form.

 

SOCIAL MEDIA AUTHORIZATION

I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, movies, or videos of the patient named above by Dr. Bryce Williams.

I also grant Dr. Bryce Williams the right to edit, use, and reuse said products for nonprofit purposes: including use in print, on the internet, and all other forms of media. I also understand that no royalty, fee, or other compensation shall become payable to me by reason of such use. I also hereby release Dr. Bryce Williams and the office employees at Williams Dental Implant and Oral Surgery from all claims, demands, and liabilities whatsoever in connection with the above.


  I DECLINE any participation in the above mentioned
 
  I ACCEPT any participation in the above mentioned
 

 
 
 


 
Signature of Patient or Representative (please hold down mouse button and sign)

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