Spring Creek Family Dentistry & Orthodontics

34 Jefferson Court

Zion Crossroads, VA 22942

540-832-3232

Welcome to our dental family. We are excited that you have decided to join our dental professionals. You are joining a General Dentistry and Orthodontic practice, which is dedicated to providing the best family dental care possible to our patients. Our office contains state of the art equipment, which we utilize to provide our patients with the highest standard of dental care possible. We are committed to providing each of our patients with the same level and quality of care that we would want provided for us.

Enclosed you will find forms that need to be completed and returned to us on your first visit. These forms are: Patient/Insurance information, How did you hear about us, Assignments of Benefits, Financial Agreement, Appointment Policy, Dental Records Transfer (Optional), HIPPA Patient Consult Form, HIPAA Notice of Privacy Practices for our office and the Health History Form. If you have Dental insurance, please bring your current insurance cards. We will remind our patients of upcoming appointments by using text and e-mail messages. Please make sure that we have your current cell phone numbers or email addresses for your reminders. At your first visit we strive to:

v Introduce you to our practice and our practice to you v Thorough review of medical and dental health history v Access periodontal (bone and gum) health v Obtain necessary radiographs to diagnose dental condition v If time permits and you have positive oral health, a dental prophy (cleaning) will be completed v Oral examination by Dentist v Review Dental Treatment recommendations v Dental Radiographs: Our offices utilize digital radiographic imaging. Viewing an enhanced digital image on

a computer screen will help our doctors to better see problem areas. Digital technology also can make it easier for you to understand any dental problems or conditions and discuss options for treatment. You may be transferring from another Dental Office. You may contact your previous Dentist to request having your records forwarded to your office. Enclosed is a form to submit requesting your records. If your previous Dentist utilizes Digital Radiographic imaging, they have the ability to email them prior to your appointment. We will take the necessary Digital Radiographs that we need to properly diagnose your Dental conditions. Our office follows the American Dental Associations (ADA) Guidelines for Dental Radiographic Examination.

We look forward to seeing you.

Sincerely,

Spring Creek Family Dentistry & Orthodontics

Spring Creek Family Dentistry & Orthodontics

34 Jefferson Court Zion Crossroads, VA 22942

540-832-3232

Patient Information Patient Name: ______________________________________________________ Address: ___________________________________________________________ City: ___________________ State: _________ Zip Code: __________________ Home #: (__) ____________ Work # (__) __________ Cell #: (__) ____________ Email: ______________________________________________________________

(We use the cell phone number and email address to remind patients of future appointments)

Patient SSN: _____________ DOB of Patient: _____________ (please circle one) Married/Single/Divorced/Widowed Driver License Number: _________________ State of Issue: ________________ How would you prefer our office to contact you? Phone/Email/Text May we leave a message for you at home/work/cell? Yes___ No ___ Primary Dental Insurance Information Insured’s Name: ___________________ Patient’s Relationship: ______________ Insured Date of Birth: __________ SSN: ______________ Phone #: ___________ Insured Employer: ____________________________________________________ Address of Employer: ______________________ City: ____________ State: ____ Insurance Name: _____________________________________________________ Address: ______________________ City: ___________ State: ____ Phone #: _________________________ Group Number: _______________________ Policy ID: ______________________ Secondary Insurance Information Insured’s Name: ___________________ Patient’s Relationship: ______________ Insured Date of Birth: __________ SSN: ______________ Phone #: ___________ Insured Employer: ____________________________________________________ Address of Employer: ______________________ City: ____________ State: ____ Insurance Name: _____________________________________________________ Address: ______________________ City: ___________ State: ____ Phone #: _________________________ Group Number: _______________________ Policy ID: ______________________

We appreciate the many referrals that we receive to our Practice. Please help us track them by filling out the following:

How did you hear about us?

Name: Information/Address:

• Dentist/Physician:

• Advertisement /Source:

• Insurance Carrier:

• Employer Referral:

• Internet/Website:

• Friend/Family:

• Other:

Would you like to refer a friend or family member? If so, Please complete the bottom portion.

Contact name: Phone #:

Address: City: State:

Assignment of Benefits Agreement For the office of

Spring Creek Family Dentistry & Orthodontics

Our practice will accept an assignment of benefits from your insurance company with the conditions listed below. It is important to understand, though, that the agreement regarding your dental benefits is between you, your employer and your insurance company the obligation you have with our practice is to pay for all treatment and services we provide to you, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.

• Although we are willing to complete insurance information forms and submit a claim on your behalf, we do not accept responsibility for the outcome of the transaction. Completing insurance forms is a courtesy we extend to you in an effort to save you time and to facilitate payment to our practice from your insurance company. By having our practice process your insurance forms, it is important that you understand that this does not eliminate your financial obligation for your treatment

• We require you to sign this agreement and/or any other necessary assignment documents that may be required by your

insurance company. This instructs your insurance company to make payment directly to our practice.

• We require you to pay the estimated copayment, which is the amount not covered by your insurance company, at the time we provide service to you. The copayment is only an estimate of charges and may be found to be insufficient after review by your insurance company.

• Insurance payments ordinarily are received within 30 days from the time of billing. If your insurance company has not

made payment to our practice within 30 days, we will ask you to pay the entire balance at that time. You will be responsible for seeking reimbursement from your insurance company at that time.

• Our practice does not guarantee that your insurance company will pay for treatment you receive from our

practice. We perform routine insurance billing procedures upon verification of coverage. However, if your claim is denied, you will be responsible for paying the full amount at that time.

• Our practice will not enter into a dispute with your insurance company over any claim, although we will provide necessary

documentation your insurance company requests to sort out any confusion or questions that may arise. We will cooperate fully with the regulations and requests of your insurance company. It is ultimately your responsibility to resolve any type of dispute over payments made or not made by your insurance company to our practice.

• WE DO NOT FILE WORKMANS COMP.

I HAVE READ AND ACCEPT THE TERMS AND CONDITINS OF THIS ASSIGNMENT OF BENEFITS AGREEMENT. I AUTHORIZE MY INSURANCE COMPANY TO PAY MY DENTAL BENEFITS DIRECTLY TO THE PRACTICE _____________________________________ _______________________ Print Name of Patient or Responsible Party Date _____________________________________ Signature of Patient or Responsible Party

Financial Agreement For the office of

Spring Creek Family Dentistry & Orthodontics

This agreement is to inform you of your financial obligation to our practice. We are committed to providing you with the most comprehensive dental care, using only the highest quality materials and technology available in the market today. We are also committed to providing you with up to date information and educational tools so that you may fully participate in maintaining optimum oral health. This financial agreement is intended to facilitate our ability to provide excellent service to you while minimizing our administrative cost. All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is an agreement between you, your employer and the insurance company. Our practice is not a party to that agreement. If payment from your insurance company is not received within (30) days from the date of service, you will be expected to pay the balance in full. As a courtesy to you we will help you process all your insurance claims. You may direct your insurance company to pay your benefits directly to our practice by signing the authorization on the assignment of Benefits Agreement. In order for our practice to file your insurance claim, you must bring a completed dental insurance form or proof of insurance at each appointment. Your estimated copayment for treatment, which is the amount not covered by your insurance, is due at the time treatment is provided. Your estimated copayment may be adjusted after the time of treatment depending upon the final reconciliation of the insurance payments. Our practice accepts cash, personal checks, Visa, MasterCard, Discover, Flex Spending Cards and money orders for payment. Third party, extended payment financing is available upon request and approval with Care Credit. Returned checks and balances older than 31 days will be subject to collection fees, finance charges at the rate of 1.5% per month (18% annually). An account over 31 days with a balance pending is your responsibility and we request you follow up with your insurance company. Accounts over 60 days will be subject to our Collection Agency. Additionally, our practice may charge you for appointments that you do not keep and for appointments that you do not cancel within 48 hours business day notice. Please do not hesitate to ask if you have any questions regarding this financial agreement. We are committed to providing you with the ultimate experience in dental care.

___________________________ ______________________________PrintNameofPatient Date___________________________ ______________________________SignatureofResponsibleParty DateofBirthofResponsibleParty ______________________________ SocialSecurity#ofResponsibleParty

Spring Creek Family Dentistry & Orthodontics

34 Jefferson Court Zion Crossroads, VA 22942

540-832-3232

Scheduled Appointments

We reserve your appointment just for you.

If you have scheduled an appointment, and you are not able to keep it, WE REQUIRE A 48 HOUR BUSINESS DAY NOTICE. If we do not receive proper notice, there will be an $85.00charge.

We understand emergencies occur; however, we want to make the appointment available for other patients. In order for us to be able to offer an open appointment to another patient, we need appropriate notice.

I have read and understand the above.

Patient / Patient Guardian Signature __________________________

Date ___/___/___

Staff Signature ___________________________________________

Date ___/___/___

Spring Creek Family Dentistry & Orthodontics 34 Jefferson Court

Zion Crossroads, VA 22942

540-832-3232

I am requesting a copy of my dental treatment records

along with copies of all full mouth series, bitewings, periapical and panoramic radiographs to be sent to:

Spring Creek Family Dentistry & Orthodontics 34 Jefferson Court Zion Crossroads, VA 22942

From: Dr:

Phone number:

If your radiographs are digital please send them via e-mail to: info@springcreekdentist.net

Patient Name: Date:

Patient/Guardian Signature: Date:

Spring Creek Family Dentistry & Orthodontics

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 Patients 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.

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 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 Policies.

• The Patient has the right to restrict the uses of their information.

• The Patient may revoke this Consent in writing at any time and all future disclosures will then cease.

• The Practice may condition treatment upon execution of this Consent. No insurance can be billed on the patient’s behalf without this signed HIPAA consent form, therefore same day of service payment in full for any services will be required.

I give my permission to discuss my treatment and or billing information with:

Relationship to patient (check one):

Spouse Δ Parent Δ Child Δ Grandparent Δ Grandchild Δ Legal Guardian

Attorney ( or representative) of patient Δ Other: This HIPAA Consent was signed by: ___________________________________

Signature of patient or guardian Printed name of same Relationship to the patient (if other than patient):

Please print Today’s Date Signature of practice representative: