Patient Informationrockycreekdental.com/wp-content/uploads/2018/07/New... · 2018. 7. 18. · Acid Reflux Depression Anxiety Insomnia Sleep Apnea Patient Name Date Male Female Height

Downtown Office1322 E. Washington Street Greenville, SC 29607 (864) 235-1200 Fax (864) 235-2512 [email protected]

Eastside Office978 Batesville Road Greer, SC 29651 (864) 675-9399 Fax (864) 675-1134 [email protected]

Dr. John Piccione Dr. Margaret Roth

Patient InformationFirst Last MI Preferred Name

Address

Apt # City State ZipHome # Work # Cell # E-mail

SSN # DOB Male Female Minor Single Married

Person responsible for account *If different from patient Relationship to you Phone # Currently a patient?

Address *If different from patient

Apt # City State ZipEMERGENCY CONTACT PRIMARY PHONE ALTERNATE PHONE RELATIONSHIP

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Dental Insurance PrimaryPolicy Holder DOB SSN # *If different from patient ID #

Employer Insurance company Insurance company phone #

Parent/Gaurdian Status *If patient is a minor Child lives withSingle Married Divorced Seperated Foster Other Parents Mother Father Grandparents Fosterparents Other

Are there court documents that require either parent to carry insurance on child? *If divorced Yes No * Please provide documentationWho has primary custody?

Additional Insurance SecondaryPolicy Holder DOB SSN # *If different from patient ID #

Employer Insurance company Insurance company phone #

I understand that I am responsible for payment of services rendered and also responsible for paying any co payment and deductibles that my insurance does not cover at the time of service. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.

Patient or Responsible Party Date

How did you hear about us?

Do you have, or have you had, any of the following?

Are you under a physician’s care now?Have you ever been hospitalized or had a major operation?Have you ever had a serious head or neck injury?Are you taking any medications, pills, or drugs?Do you take, or have you taken, Phen-Fen or Redux?Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphonates?Are you on a special diet?Do you use tobacco?Have you ever been diagnosed with sleep apnea?If so do you use a CPAP or Bipap machine?Women are you...Pregnant/ trying to get pregnant?Are you allergic to any of the following?Aspirin Penicillin Codeine Acrylic Metal Latex Sulfa Drugs Local AnestheticsDo you use controlled substances?

Patient Name DOB Date Created

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Other

If Yes

If Yes

Radiation TreatmentsRecent Weight LossRenal DialysisRheumatic FeverRheumatismScarlet Fever ShinglesSickle Cell DiseaseSinus TroubleSpina BifidaStomach/Intestinal DiseaseStrokeSwelling of LimbsThyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersVenereal Disease

HemophiliaHepatitis AHepatitis B or CHerpesHigh Blood PressureHigh CholesterolHives or RashHypoglycemiaIrregular HeartbeatKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve ProlapseOsteoporosisPain in Jaw JointsParathyroid DiseasePsychiatric Care

Cortisone MedicineDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingExcessive ThirstFainting Spells/DizzinessFrequent CoughFrequent DiarrheaFrequent HeadachesGenital HerpesGlaucomaHay FeverHeart Attack,FailureHeart MurmurHeart PacemakerHeart Trouble/Disease

AIDS/HIV PositiveAlzheimer’s DiseaseAnaphylaxisAnemiaAnginaArthritis/GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood TransfusionBreathing ProblemsBruise EasilyCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DisorderConvulsionsYellow Jaundice

Yes NoYes No Yes No Yes No

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes In medical status.

If YesYes NoHave you ever had any serious illness not listed above?

Yes No

Yes No Nursing? Taking oral contraceptives?

Yes No

Medical History

Patient or Responsible Party Date

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Comments

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Individual refused to signCommunications barriers prohibited obtaining the acknowledgmentAn emergency situation prevented us from obtaining acknowledgmentOther (Please specify)

We attempted to obtain written acknowledgment or receipt of our Notice of Privacy Practices, but acknowledgment could not be obtained because

For office use only

Signature of Patient /Legal Guardian

Date

Please Print NameI, , have received a copy of this office's Notice of Privacy Practices.

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Printed Name of Legal Guardian If applicableSignature of Patient /Legal Guardian

Date

Printed Name of Patient

HIPAA Authorization FormBecause communication is vital and necessary for patient treatment, it is the policy of this practice to contact you by leaving messages and/or speaking with family members. This information includes:

Appointment/ Prescription Refill Reminders Preoperative and Postoperative Information Treatment or other Information pertinent to your healthcare Billing and Collection Information

If you request that our office communicate with you in a more confidential manner, please submit your request in writing for documentation purposes.




Signature of Patient /Legal Guardian Date

We are pleased to welcome you to our office. New Patients are always appreciated. Our practice has grown as a result of excellent relationships with our referring patients and doctors. As our patient, please feel free to express any concerns or ask any questions that you may have. Our doctors and our staff will do our best to help.

To assist you in paying for treatment, we offer several payment options. Please read our financial policy below and feel free to discuss it with us.

Payment for services will be expected in full unless arrangements are made in advance of treatment. Payments can be made with Cash, Check, ATM/Debit, Visa, Master Card, American Express, Discover or Care Credit (Please ask for details). Any check returned will be assessed a return check fee of $30. In the event that a delinquent account is turned over to an outside collection agency, the patient is responsible for the collection agency's fees.

If financial arrangements are necessary, we offer a payment plan, which can be customized to suit your needs. Please advise one of our administration staff and they will assist you.

Any account with a balance remaining after 90 days will be assessed a fee of 18% annually, regardless of any outstanding insurance claims.

With your approval, we will file your insurance claims with your insurance carrier. This service is provided at no charge. You can elect to pay your balance in full and have your benefits paid directly to you or you can elect to have benefits paid to our office. If the latter is chosen, we will ESTIMATE your co-pay, due at each appointment. We reserve the right to estimate your benefits based on our previous experience.

Any balance not covered by your insurance is your responsibility. However, if at any point the insurance company or the insured becomes uncooperative, we reserve the right to terminate acceptance of benefits and collect payment directly from you.

Our doctors and team at Rocky Creek Dental Care make every attempt to provide you with the highest quality and undivided appointment time for your dental treatment. We reserve this time specifically for you. If you are unable to keep your scheduled appointment, kindly provide us with at least 24 hour notice. We realize there are true emergencies and unforeseen interruptions in life, and we will, of course, take these into consideration. Appointments that are missed or cancelled with less than a 24 hour notice will result in a charge of $50 for each scheduled appointment. Three missed appointments within a 12 month period will result in eligibility for discharge from the practice.

If you have insurance

Office Financial Policy

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Cancellation Policy



If yes every night?Are you currently using a CPAP Bipap machine?Have you ever had a sleep study?Do you have frequent headaches?Do you wake up with soreness or tension in your jaw muscles or teeth?

Please check any of the following you may have

High Blood Pressure Heart Disease Diabetes Stroke Weight GainAcid Reflux Depression Anxiety Insomnia Sleep Apnea

Patient Name Date

Male Female Height Weight DOB General Physician

Dental Care Sleep Questionnaire

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Yes No

Yes No Severity

Yes No

For Clinical Use OnlyLow Moderate High Severe0–7 8–11 12–15 16+

Have you ever been told you stop breathing while you sleep?Have you ever fallen asleep or nodded off while driving?Have you ever woken up suddenly with shortness of breath, gasping, or racing heart?Do you fight sleepiness during your normal daytime routine?Do you snore, or have you been told that you snore?Have you had weight gain and found it difficult to lose?Have you taken medication for, or been diagnosed with high blood pressure?Do you jerk your legs while sleeping?Do you feel burning, tingling, or crawling sensations in your legs when you wake up?Do you wake up with headaches during the night or morning? Do you have trouble falling asleep?Do you have trouble staying asleep once you fall asleep?

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Documents

Patient Informationrockycreekdental.com/wp-content/uploads/2018/07/New... · 2018. 7. 18. · Acid Reflux Depression Anxiety Insomnia Sleep Apnea Patient Name Date Male Female Height