Dr. Jeremy Mills DDS - New Patient Paperwork

W E L C O M E
PATIENT INFORMATION
Date

Month Day Year
Date
Social Security/HIC/Patient ID Number
Patient Name *

First Name Middle Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Sex
Birthdate

Month Day Year
Date
Age
Marital Status
For how many years?
Patient Employer/School
Occupation
Employer/School Address

Street Address

Street Address Line 2

City State / Province
Employer/School Phone
Please enter a valid phone number.
Spouse's Name

First Name Last Name
Birthdate

Month Day Year
Date
Social Security Number
Spouse's Employer
Whom may we thank for referring you?

DENTAL INSURANCE
Who is responsible for this account?

First Name Last Name
Relationship to Patient
Insurance Company
Group Number
Is patient covered by additional insurance?

Yes No
Subscriber's Name

First Name Last Name
Birthdate

Month Day Year
Date
Social Security Number
Relationship to Patient
Insurance Company
Group Number
ASSIGNMENT AND RELEASE
I certify that I, and/or my dependent(s), have insurance coverage with {insuranceCompany}, {insuranceCompany199} and assign directly to Dr. Jeremy Mills, DDS all insurance benefits if 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 authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits of the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
Signature *

Patient, Parent, Guardian or Personal Representative Clear
Name of Patient, Parent, Guardian or Personal Representative

First Name Last Name
Date

Month Day Year
Date
Relationship to Patient

PHONE NUMBERS
Phone Number
Please enter a valid phone number.
Alternate Phone
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Ext
Spouse's Work Number
Please enter a valid phone number.
Best time and place to reach you
IN CASE OF EMERGENCY CONTACT (Specify someone who does not live in your household)
Name

First Name Last Name
Relationship
Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.

FINANCIAL POLICY
To Our Valued Patients:

In this world of rising prices, we are trying to keep our fees at a minimum by implementing the following payment policies.

All Payments for services are due at the time services are rendered. We accept Visa, MasterCard, Discover, Bank Cards, Care Credit, and Check.

All patients are expected to pay for treatment regardless of dental insurance. Once insurance coverage and benefits have been verified, our policies are as follows:
- For Restorative care, the patient will be required to pay the deductible and estimated portion of the fee at the time services are rendered. You will be responsible for any balance remaining after your insurance company has paid or denied the claim.
- I understand that my contact with my insurance carrier is between my insurance carrier and myself and I am responsible for any charges that my insurance does not cover such as office visits, x-rays, and laboratory fees.
- As a patient, I am responsible for informing the office of any changes regarding my insurance and contact information.
- Your appointment time in this office is reserved especially for you. Please note that three or more missed appointments may be grounded for dismissal from this practice.
- I understand that there will be a $35.00 charge for broken appointments unless 24 hours of notice is given.
Name

First Name Last Name
Signature *

Clear
Date

Month Day Year
Date

APPOINTMENT AND CANCELLATION POLICY
Appointment Policy

An Appointment in our schedule is a bond of trust that we will be here to serve you and you will be present for treatment. We strive to create a schedule that provides for the dental needs of all the patients we serve.

Our Appointment Policy

Please arrive on-time to your scheduled appointment. Late arrivals cause schedule delays for those patients who arrive promptly at their appointment time. Late arrivals will be worked into the schedule if time allows or re-appointed to another day. Our office policy is firm in this regard.

Cancellations

Additionally, while we understand that things may come up, it's very important that we receive notice of a change in plans at least 24-hours in advance. Otherwise, there will be a $35.00 charge added to your account.

We respect our patient's time and make every effort to remain on schedule. Some visits are more complicated than initially anticipated and emergencies may arise that could delay us. If we are significantly delayed, every effort will be made to notify you beforehand, so you may choose to come later or reschedule. If you are going to be late, we ask that you please notify us. If you are significantly delayed, your scheduled treatment may be notified, or you may be asked to reschedule your appointment.

Cancellation Policy

Because of the level of service we provide our patients, your appointment is especially held just for you, so that we have the right amount of time for your procedure at our office. When patients do not show for their appointment or do not give us adequate cancellation notice, we are not given the opportunity to reschedule that time with another patient who has a true dental need.

Thank you for understanding the value of our cancellation policy to each of our patients.

Office Procedures

Verbal Authorization: It is our office procedure to get verbal authorization from all new patients to confirm appointments. It is also our procedure that we get your insurance information, so we can confirm the status of your insurance and get prior authorization for treatment as needed.

I authorize the following person/persons to be my personal representative, which means the doctor and staff speak freely to the named personal representative regarding all protected health information, medical and treatment matters to billing.
Patient Signature *

Clear
Date

Month Day Year
Date
I First Name Last Name , authorize this facility to examine and provide dental treatment. I assume full responsibility for any balance due. I authorize my insurance company to pay by check made out directly to this facility. I authorize this facility to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit. I understand it is my responsibility to know all rules and restrictions of my insurance policy, to know which hospital, emergency rooms, laboratories, x-ray departments and specialists and specialist providers which are assigned to me according to my insurance policy rule. It is this facility's procedures to share protected health information with labs, x-rays, consulting physicians and hospitals. We will call the pharmacy of your choice regarding your prescriptions. We will only exchange minimum necessary protected health information for each transaction.

Our office is HIPAA-compliant and the staff has been trained in the HIPAA privacy act. We will do everything we can to protect your patient health information.

However, our office was designed before the HIPAA law so please be respectful of other patient's privacy.

I, First Name Last Name (Patient's Name), agree to all of the above office procedures of this facility, and give my authorization to all of the above procedures.
Patient Signature *

Clear
Date

Month Day Year
Date

HIPAA
ACKNOWLEDGEMENT OF OUR NOTICE OF PRIVACY PRACTICES
I hereby acknowledge that I have received or have been given the opportunity to receive a copy of Dr. Jeremy Mills, DDS Notice of Privacy Practices. By signing below, I am "only" giving acknowledgment that I have received or have had the opportunity to receive the Notice of Privacy Practices.
Patient Name

First Name Last Name
Signature *

Clear
Date

Month Day Year
Date
Please verify that you are human *
Should be Empty:

W E L C O M E

PATIENT INFORMATION

DENTAL INSURANCE

ASSIGNMENT AND RELEASE

PHONE NUMBERS

DENTAL HISTORY

HEALTH HISTORY

Women

Medications

Updates

FINANCIAL POLICY

APPOINTMENT AND CANCELLATION POLICY

HIPAA

ACKNOWLEDGEMENT OF OUR NOTICE OF PRIVACY PRACTICES