lincolnwaydentalcenter.com - New Patient Packet

New Patient
Patient Information
Date

MonthDayYear
Date
Name:

First NameLast Name
Birth date:

MonthDayYear
Date
SS#:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Please enter a valid phone number.
Cell Phone:
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
Email:
example@example.com
Sex:

MaleFemale
Marital Status:
Employer/School:
Employer/School Phone:
Please enter a valid phone number.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse/Parents Name:
Employer:
Phone Number:
Please enter a valid phone number.
Emergency Contact Name:
Emergency Contact Phone:
Please enter a valid phone number.
Responsible Party
Person Responsible for Account:
Relationship to Patient:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Drivers License#:
Birth date:

MonthDayYear
Date
Employer:
Work Phone:
Please enter a valid phone number.
Cell Phone:
Please enter a valid phone number.
Currently a Patient in our office?

YesNo
Email:
example@example.com
Insurance Information
Name of Insured:
Relationship to Patient:
Birth date:

MonthDayYear
Date
Social Security #:
Date employed:
Employer:
Work Phone:
Please enter a valid phone number.
Insurance Company:
Group #:
Union/Local#:
Union/Local#:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Maximum Benefit:
Deductible:
Benefits used this year:
Additional Insurance
Name of Insured:
Relationship to Patient:
Birth date:

MonthDayYear
Date
Social Security #:
Date employed:

MonthDayYear
Date
Employer:
Work Phone:
Please enter a valid phone number.
Insurance Company:
Group #:
Union/Local#:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Maximum Benefit:
Deductible: $
Benefits used this year:

Photo and Testimonial Release
I,   Name ,  HEREBY GRANT PERMISSION TO (office name), TO USE MY PHOTOGRAPHS, AND ANY TESTIMONIAL I GIVE REGARDNG THE MEDICAL CARE I RECEIVE FROM THIS OFFICE, IN ANY MARKETING, ADVERTISING OR TEACHING MATERIALS USED TO MARKET OR ADVERTISE THEIR MEDICAL PRACTICE, INCLUDING USE ON A PROFESSIONAL WEBSITE. I ACKNOWLEDGE THE OFFICE'S RIGHTS TO CROP OR OTHERWISE TREAT THE PHOTOGRAPH AT THEIR DISCRETION. I ALSO ACKNOWLEDGE THAT THEY MAY CHOOSE NOT TO USE MY PHOTOGRAPH AND TESTIMONIAL AT THIS TIME, BUT MAY DO SO AT THEIR OWN DISCRETION AT A LATER DATE. I UNDERSTAND THAT THE IMAGES WILL NOT BE IDENTIFIED BY NAME, BUT THAT SUCH PHOTOGRAPHS, VIDEOTAPES, COMPUTER IMAGES, AND/OR INTERNET IMAGES MAY REVEAL MY IDENTITY AND I ACCPT THIS LOSS OF ANONYMITY. I ALSO UNDERSTAND THAT ONCE MY IMAGE IS POSTED ON A WEBSITE, THE IMAGE CAN BE DOWNLOADED BY ANY COMPUTER USER, WHICH IS BEYOND THE CONTROL OF (office name), AND I WILL HOLD THE OFFICE AND ANY OF THEIR AFFILIATED OFFICES HARMLESS FROM ANY SUCH USE OR DOWNLOAD. I UNDERSTAND THAT IMAGES RELEASED BY THIS AUTHORIZATION AND FURTHER DISCLOSED BY THE RECIPENT MAY NO LONGER BE PROTECTED BY FEDERAL AND STATE LAW AND MAY BE MODIFIED OR USED FOR UNINTENDED OR UNANTICIPATED PURPOSES INCLUDING FOR COMMERCIAL GAIN.

Initials  I HEREBY FREELY AND VOLUNTARILY CONSENT TO THE USE OF MY PHOTOGRAPH AND TESTIMONIAL AS STATED ABOVE UNLESS I REVOKE THIS CONSENT IN WRITING BY A WRITTEN NOTICE. I UNDERSTAND THAT A REVOCATION IS NOT EFFECTIVE TO THE EXTENT THAT (office name) HAVE ALREADY DISCLOSED THE PROTECTED HEALTH INFORMATION.

Initials  I HAVE ENTERED INTO THIS AGREEMENT WILLINGLY AND HEREBY WAIVE ANY RIGHT TO COMPENSATION FOR SUCH USES. I ALSO STATE THAT I AND MY SUCCESSORS OR ASSIGNS HEREBY HOLD HARMLESS (office name) FROM AND AGAINST ANY CLAIM FOR INJURY OR COMPENSATION RESULTING FROM THE ACTIVITIES AUTHORIZED BY THE AGREEMENT.

Initials  THE TERM "PHOTOGRAPH" OR "PHOTO" AS USED IN THIS AGREEMENT SHALL ALSO INCLUDE MOTION PICTURES OR VIDEOS, OR ANY OTHER STILL, DIGITAL, MECHANICAL OR ELECTRONIC MEANS OF REPRODUCING IMAGES.

Initials  I FURTHER CONSENT TO THE RELEASE AND TRANSFER OF COPYRIGHT OWNERSHIP BY (office name) OF SUCH IMAGES AND PHOTOS. I UNDERSTAND THAT SUCH IMAGES AND PHOTOS MAY BE PUBLISHED BY THE OFFICE, OR ANY PARTY ACTING UNDER LICENSE AND AUTHORITY OF THE OFFICE, IN ANY PRINT, VISUAL OR ELECTRONIC MEDIA„ SPECIFICALLY INCLUDING, BUT NOT LIMITED TO MEDICAL JOURNALS AND TEXTBOOKS, SCIENTIFIC PRESENTATIONS, AND TEACHING COURSES AND INTERNET WEBSITES, FOR PURPOSE OF INFORMING THE MEDICAL PROFESSION OR GENERAL PUBLIC ABOUT METHODS, RESULTS, ISSUES, TRENDS,CONCERNS AND SIMILAR MATTERS. I FURTHER UNDERSTAND THAT THE IMAGING RECORDS SHALL BECOME THE PROPERTY OF THE OFFICE IF SO USED BY THEM OR THEIR AUTHORIZED USERS.

Initials  I UNDERSTAND THAT THE INFORMATION AND LIKENESS DISCLOSED OR SOME PORTION THEREOF, MAY BE PROTECTED BY STATE LAW, FEDERAL LAW AND OR THE FEDERAL HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 ("HIPAA"). I FURTHER UNDERSTAND THAT BECAUSE (office name) ARE NOT RECEIVING THE INFORMATION IN THE CAPACITY OF HEALTH CARE PROVIDER OR HEALTH PLAN COVERED BY HIPAA, THE INFORMATION DESCRIBED ABOVE MAY NO LONGER BE PROTECTED BY HIPAA AND MAY BE REDISCLOSED.

Initials  I UNDERSTAND THAT I MAY REFUSE TO SIGN THIS AUTHORIZATION AND SUCH REFUSAL WILL HAVE NO EFFECT ON THE MEDICAL TREATMENT I RECEIVE FROM (office name).
Patient Signature

Clear
Parent/Guardian Signature (If under 18)

Clear
Date

MonthDayYear
Date
Printed Name
Parent/Guardian Print Name (If under 18)
Date

MonthDayYear
Date

Our Financial Policies

Your Dental Insurance
We are committed to providing you with the best possible care. If you have dental insurance, we want to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our financial policies. Please be sure to read this form in its entirety and sign at the bottom.

We encourage our patients to be familiar with the cost of their dental treatment. A fee estimate is available to you before you consent to treatment. If you like an estimate, please be sure to request one.
- Patients without insurance: Please make payment for your care at each office visit. The following methods of payment are offered: Cash or Check, Visa, MasterCard, American Express and Discover. We also offer financing plans through CareCredit Financing.
- Your insurance is a contract between you, your employer and the insurance company. We are not a third party to that contract. As a service to you, we will help your file your insurance claim for reimbursement, providing we have complete and current insurance information. However, we consider the patient responsible for the account.
- Not all services are a covered benefit in all contracts. The insurance coverage purchased by your employer selects certain services they will not cover. You are responsible for deductibles and noncovered services. Please pay the estimated portion as services are rendered. The remaining balance should be paid within 10 days after receipt of our billing statement.
- If you have any questions concerning our financial policies or uncertainty regarding insurance coverage, PLEASE do not hesitate to ask. We are here to help you.
- A note to divorced parents: The parent who brings the patient to our office will be responsible for our professional fees unless specific alternate arrangements are made in advance.
- To avoid broken appointment fee, we kindly ask for 48 hours’ notice for all cancellations.
I have read and agree to the Financial Policy stated above that applies to me.
Signature of Financially Responsible Party

Clear
Date

MonthDayYear
Date

Privacy Policy
Lincolnway Dental Center, P.C. Privacy Policy

This Privacy Policy discloses the privacy practices for www.lincolnwaydentalcenter.com. This notice applies solely to the information collected by this website. It will notify you of the following:
1. What personally identifiable information is being collected form you through the website, how it is used and with whom it is shared
2. What choices are available to you regarding the use of your data.
3. The security procedures in place to protect the misuse of your information.
4. How you can correct any inaccuracies in the information.
Information Collection, Use & Sharing

We are the sole owners of the information collected on this website. We only have access to/collect information that you voluntarily give us via email or other direct contact from you. We will not sell or rent this information to anyone.

We will only use your information to respond to you regarding the reason you contacted us. We will not share your information with any third party outside of our organization, other than necessary to fulfill your request (eg, to ship an order).

Unless you ask us not to, we may contact you via email in the future to tell you about specials, new products or services, or changes to this policy.

Your Access To & Control Over Information

You may opt out of any future contacts from us at any time. You can do the following at any time by contacting us via the email address or phone number given on our website:
- See what data we have about you, if any
- Change/correct any data we have about you
- Have us delete any data we have about you
- Express any concern you have about our use of your data
Security

We take precautions to protect your information. When you submit sensitive information via the website, your information is protected both online and offline.

Whenever we collect sensitive information (such as credit card data) that information is encrypted and transmitted to us in a secure way. You can verify this by looking for a closed lock icon at the bottom of your web browser, or looking for “https” at the beginning of the address of the webpage.

While we use encryption to protect sensitive information transmitted online, we also protect your information offline. Only employees who need the information to perform a specific job (ie, billing or customer service) are granted access to personally identifiable information. The computers/servers in which we store personally identifiable information are kept in a secure environment.

If you feel that we are not abiding by this Privacy Policy, you should contact us immediately via telephone at 630-897-1300.

Appointment Cancellation Policy
We strive to render excellent dental care to you and the rest of our patients. In an attempt to be consistent with this, we have an Appointment Cancellation Policy that allows us to schedule ] appointments for all patients. When an appointment is scheduled, that time has been set aside for you and when it is missed, that time cannot be used to treat another patient.

Our policy is as follows:

We require that you give our office 48 hours notice in the event that you need to reschedule your appointment. This allows for other patients to be scheduled in the available appointment. If you miss an appointment without contacting our office within the required time, this is considered a missed appointment. A fee of $55.00 will be charged to you; this fee cannot be billed to your insurance company and will be your direct responsibility. No future appointments can be scheduled nor can records be transferred without the payment of this fee.

Additionally, if a patient is more than 20 minutes late without prior notice for a scheduled appointment, we will consider this a missed appointment and the $55.00 cancellation fee will be charged.

If you have any questions regarding this policy, please let our staff know and we will be glad to clarify any questions you have.

I have read and understand the Appointment Cancellation Policy of the practice and I agree to be bound by its terms. I also understand and agree that such terms may be amended from time-to-time by the practice.
Patient/Responsible Party Signature

Clear
Date

MonthDayYear
Date

HIPAA PATIENT CONSENT FORM
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The patient understands that:
- Protected health information may be disclosed or used for treatment, payment, or health care operations.
- The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.
- The Practice reserves the right to change the Notice of Privacy Practices.
- The patient has the right to restrict the uses of their information but the Practice does not have to agree to the restrictions.
- The patient may revoke this Consent in writing at any time and all future disclosures will then cease.
- The Practice may condition receipt of treatment upon the execution of this Consent.
- The patient acknowledges that he/she has received a copy of our HIPAA practices brochure.
  ( Please ask for copy )
The Consent was signed by:
Printed Name, Patient or Representative
Relationship to Patient(if other than patient):
Should be Empty:

New Patient

Patient Information

Responsible Party

Insurance Information

Additional Insurance

Medical History

Dental History

Medical History

Authorization and Release

Photo and Testimonial Release

Our Financial Policies

Privacy Policy

Appointment Cancellation Policy

HIPAA PATIENT CONSENT FORM