APPLICATION FOR TREATMENT Chart # Herman Ostrow School of Dentistry of USC Patient Information (To be completed by the patient – Please PRINT in ink) Mr. ( ) Mrs. ( ) Ms. ( ) Last Name: __________________________________________________ Date: _____ /_____ / _____ First Name: _________________ (Preferred Name) _________________ Middle Name: ______________ Billing Address: ________________________________________________________________________ City: __________________________________________ State: _________ Zip Code:______________ Home Phone: ( ) ______________________________ Work Phone: ( ) _______________________ Preferred Phone: ( ) ____________________________ Email Address: _________________________________ Driver’s License: ________________________________ California ID: ________________ [ ] Other ____________ Passport: _____________________ Employer: _____________________________________ Sex: [ ] Male [ ] Female [ ] Other Birth date: _____________________________________ Primary Language(s) Spoken: ______________________ Are you associated with U.S.C.? Yes [ ] No [ ] If so, how? _____________________________________ Student Requested: ______________________________ Emergency Contact: _____________________________ Relationship: __________________________ Emergency Contact Phone: ( ) ___________________ Major dental problem/reason for coming to USC School of Dentistry: ______________________________ Last Dentist: _______________________________________________________ Phone: ( ) _________ Address: ___________________________________ City: ___________ State:_________ Zip:_______ Current Medical Doctor: ________________________________________ Phone: ( ) ______________ Address: ___________________________________ City: ___________ State:_________ Zip:_______ Insurance/Financial Information (To be completed by the patient – Please PRINT in ink) Previously a patient here? [ ] Yes [ ] No Year:___ Insurance: [ ] Delta [ ] Delta/USC [ ] Denti-Cal [ ] Other Carrier Name: _________________________________________________________________________ Subscriber: ____________________________ Subs. #: Subs. Birthdate: Relationship: ______________________ Plan #: Group #: Person Responsible for Payment: __________________________________ Phone: ________________ Please be aware that your dental insurance may not pay for the total amount of your treatment and you may be responsible for any co-pays or amount that your insurance company does not cover. Revised 6/12, 6/13, 3/15, 6/15,10/2015 Ethnicity: (please select) [ ] African American [ ] Asian [ ] Caucasian [ ] Hispanic [ ] American Indian/Alaskan native [ ] Pacific Islander [ ] Unknown [ ] Other To guide us in assigning a student whose schedule matches your availability, You must indicate at least 3 with a þ the sessions for which you are regularly available: Note: AM session 8:00am and PM session is 1:00pm r Monday AM r Monday PM r Tuesday PM r Tuesday Night Clinic r Wednesday AM r Wednesday PM r Wednesday Night Clinic r Thursday AM r Thursday PM r Friday AM r Friday PM
Transcript
APPLICATION FOR TREATMENT Chart #
Herman Ostrow School of Dentistry of USCPatient Information (To be completed by the patient – Please PRINT in ink) Mr. ( ) Mrs. ( ) Ms. ( ) Last Name: __________________________________________________ Date: _____ / _____ / _____
First Name: _________________ (Preferred Name) _________________ Middle Name: ______________
Major dental problem/reason for coming to USC School of Dentistry: ______________________________ Last Dentist: _______________________________________________________ Phone: ( ) _________ Address: ___________________________________ City: ___________ State: _________ Zip: _______ Current Medical Doctor: ________________________________________ Phone: ( ) ______________ Address: ___________________________________ City: ___________ State: _________ Zip: _______ Insurance/Financial Information (To be completed by the patient – Please PRINT in ink) Previously a patient here? [ ] Yes [ ] No Year:___ Insurance: [ ] Delta [ ] Delta/USC [ ] Denti-Cal [ ] Other Carrier Name: _________________________________________________________________________ Subscriber: ____________________________ Subs. #: Subs. Birthdate: Relationship: ______________________ Plan #: Group #: Person Responsible for Payment: __________________________________ Phone: ________________
Please be aware that your dental insurance may not pay for the total amount of your treatment and you may be responsible for any co-pays or amount that your insurance company does not cover. Revised 6/12, 6/13, 3/15, 6/15,10/2015
Ethnicity: (please select) [ ] African American [ ] Asian [ ] Caucasian [ ] Hispanic [ ] American Indian/Alaskan native [ ] Pacific Islander [ ] Unknown [ ] Other
To guide us in assigning a student whose schedule matches your availability, You must indicate at least 3 with a þ the sessions for which you are regularly available: Note: AM session 8:00am and PM session is 1:00pm
r Monday AMr Monday PM
r Tuesday PM r Tuesday Night Clinic
r Wednesday AMr Wednesday PM r Wednesday Night Clinic
r Thursday AMr Thursday PM
r Friday AMr Friday PM
WELCOME TO THE
HERMAN OSTROW SCHOOL OF DENTISTRY OF USC
Today you will be screened by one of the school faculty. The faculty will decide if your oral condition is:
A. An emergency case.
B. Not a case that we can offer treatment at this school.
C. A teaching case for our post-graduate students.
D. A teaching case for our pre-doctoral dental students.
A) If your oral condition is an emergency case, you will be referred to our Urgent Care Clinic in this
building.
B) If your oral condition is a case that we cannot treat at this school, we will provide you with information
about other low fee clinics.
C) If your oral condition is a teaching case for our post-graduate students; you will be redirected to a specific
clinic in the school that can better address your needs. These post-graduate clinics will have their own
appointment schedules and their own screening processes. We cannot guarantee that the faculty of a post-
graduate clinic will accept your case.
D) If your oral condition is a teaching case for our pre-doctoral dental students:
You MUST select at least 3 clinic sessions on the application to be accepted as a patient.
We will first make sure that you understand and agree with the Dental Students’ Clinic Policies
(please read the next section for details).
You will then be sent to the cashier to pay between $20-$100. The fee includes your admitting fee,
and your X-rays (panoramic and/or full mouth X-rays when necessary).
After paying your fee at the cashier, have a seat and you will be called by radiology department.
Show proof of payment to radiology staff.
X-rays: A panoramic X-ray and/or a full mouth X-rays will be done if necessary.
A fee in the amount of $55 will be due at your next appointment with your assigned dental student
for data collection and treatment planning.
A pre-doctoral dental student will call you within then FOUR WEEKS to set up your next
appointment.
If you do not receive a call from the assigned pre-doctoral dental student within this period. Please
call the Administrative Assistant from your assigned group and say you are waiting for your
appointment.
For group A: Call Francise Ochoa (213) 740-7403
For group B: Call Deisy Silva (213) 740-8139
For group C: Call Yvonne Mercado (213) 740-6529
For group D: Call JoAnne Williams (213) 821-5283
For group E: Call Naira Ohanian (213) 740-1574
For group F: Call Brenda Castillos (213) 740-2678
For group G: Call Tara Lam (213) 740-6485
For group H: Call Laurie Delguidice (213) 740-4614
For group I: Call Vilma Arlotti (213) 740-4517
OCR NOTICE OF NONDISCRIMINATION
Source: HHS Office for Civil Rights
Herman Ostrow School of Dentistry of USC
complies with applicable Federal civil rights laws and does not discriminate on the basis of
race, color, national origin, age, disability, or sex.
Herman Ostrow School of Dentistry of USC
does not exclude people or treat them differently because of race, color, national origin, age,
disability, or sex.
Herman Ostrow School of Dentistry of USC:
Provides free aids and services to people with disabilities to communicate effectively
with us, such as:
○ Qualified sign language interpreters
○ Written information in other formats (large print, audio, accessible electronic
formats)
• Provides free language services to people whose primary language is not English, such as:
○ Qualified interpreters
○ Information written in other languages
If you need these services, contact Douglas C. Solow DDS, MBA, Office of Clinical Affairs,
(213) 740-1547
If you believe that Herman Ostrow School of Dentistry of USC
has failed to provide these services or discriminated in another way on the basis of race,
color, national origin, age, disability, or sex, you can file a grievance with:
You can file a grievance in person or by mail, fax, or email. If you need help filing a
grievance, USC Office of Equity and Diversity is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human
Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint
Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services, 200
Independence Avenue SW.
Room 509F, HHH Building
Washington, DC 20201
Toll Free: 1-800-868-1019, 800-537-7697
(TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
It is the policy of the Herman Ostrow School of Dentistry of USC not to discriminate based on race, color, national origin, sex, age or disability. The Herman Ostrow School of Dentistry of USC has adopted an internal grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by Section 1557 of the Affordable Care Act (42 U.S.C. 18116) and its implementing regulations at 45 CFR part 92, issued by the U.S. Department of Health and Human Services. Section 1557 prohibits discrimination based on race, color, national origin, sex, age or disability in certain health programs and activities. Section 1557 and its implementing regulations may be examined in the USC Office of Equity and Diversity, 3720 S. Flower Street, 2nd floor, Credit Union Bldg. 200. Los Angeles, CA 90089-0704, Phone: (213) 740-5086, FAX (213) 740-5090, [email protected], who has been designated to coordinate the efforts of Herman Ostrow School of Dentistry of USC to comply with Section 1557.
Any person who believes someone has been subjected to discrimination based on race, color, national origin, sex, age or disability may file a grievance under this procedure. It is against the law for Herman Ostrow School of Dentistry of USC to retaliate against anyone who opposes discrimination, files a grievance, or participates in the investigation of a grievance. Procedure:
Grievances must be submitted to the Section 1557 Coordinator within (60 days) of the date the person filing the grievance becomes aware of the alleged discriminatory action.
A complaint must be in writing, containing the name and address of the person filing it. The complaint must state the problem or action alleged to be discriminatory and the remedy or relief sought.
The Section 1557 Coordinator (or her/his designee) shall conduct an investigation of the complaint. This investigation may be informal, but it will be thorough, affording all interested persons an opportunity to submit evidence relevant to the complaint. The Section 1557 Coordinator will maintain the files and records of Herman Ostrow School of Dentistry of USC relating to such grievances. To the extent possible, and in accordance with applicable law, the Section 1557 Coordinator will take appropriate steps to preserve the confidentiality of files and records relating to grievances and will share them only with those who have a need to know.
The Section 1557 Coordinator will issue a written decision on the grievance, based on a preponderance of the evidence, no later than 30 days after its filing, including a notice to the complainant of their right to pursue further administrative or legal remedies.
The person filing the grievance may appeal the decision of the Section 1557 Coordinator by writing to the USC Office of Equity and Diversity within 15 days of
Grievance Procedure for Section 1557 Covered Practices with 15 or More Employees
receiving the Section 1557 Coordinator's decision. The USC Office of Equity and Diversity shall issue a written decision in response to the appeal no later than 30 days after its filing.
The availability and use of this grievance procedure does not prevent a person from pursuing other legal or administrative remedies, including filing a complaint of discrimination based on race, color, national origin, sex, age or disability in court or with the U.S. Department of Health and Human Services, Office for Civil Rights. A person can file a complaint of discrimination electronically through the Office for Civil Rights Complaint Portal, which is available at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201. Complaint forms are available at: http://www.hhs.gov/ocr/office/file/index.html. Such complaints must be filed within 180 days of the date of the alleged discrimination. The Herman Ostrow School of Dentistry of USC will make appropriate arrangements to ensure that individuals with disabilities and individuals with limited English proficiency are provided auxiliary aids and services or language assistance services, respectively, if needed to participate in this grievance process. Such arrangements may include, but are not limited to, providing qualified interpreters, providing taped cassettes of material for individuals with low vision, or assuring a barrier-free location for the proceedings. The Section 1557 Coordinator will be responsible for such arrangements.
