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New Patient Form (Testing Copy)

New Patient Form (Testing Copy)

To become a new patient of Premier Dental of St George, fill out the information below:

Patient Information

Mailing Address
City
State/Province
Zip/Postal
Country

Have you ever had any of the following?

Please check all that apply

For Women

Agreement

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any changes in my health, I will inform the doctors at the next appointment without fail.

Spouse or Responsible Party Information

Spouse/Responsible Address:
City
State/Province
Zip/Postal
Country

Employment Information

Address
City
State/Province
Zip/Postal
Country

Insurance Information

Primary
Name of Insured:
Insured's Address:
City
State/Province
Zip/Postal
Country
Insured's Employer Address:
City
State/Province
Zip/Postal
Country

Insurance Information

Secondary
Name of Insured:
Insured's Address:
City
State/Province
Zip/Postal
Country
Insured's Employer Address:
City
State/Province
Zip/Postal
Country

Insurance Authorization

I authorize my insurance to pay the dentist or dental group all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature of all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

Consent to Proceed

I authorize Dr. Mark A. Baker and/or such associates or assistants as s/he may designate to perform those procedures as may be deemed necessary or advisable to maintain my dental health or the dental health of any minor or other individual for which I have responsibility, including arrangement and/or administration of any sedative (including nitrous oxide), analgesic, therapeutic, and/or other pharmaceutical agent(s), including those related to restorative, palliative, therapeutic or surgical treatments. I understand that the administration of local anesthetic may cause an untoward reaction or side effects, which may include, but are not limited to bruising, hematoma, cardiac stimulation, muscle soreness, and temporary or rarely, permanent numbness. I understand that occasionally needles break and may require surgical retrieval. Occasionally drops of local anesthetic may contact the eyes and facial tissues and cause temporary irritation. I understand that as part of the dental treatment, including preventive procedures such as cleanings and basic dentistry, including fillings of all types, teeth may remain sensitive or even possibly quite painful both during and after completion of treatment. Dental materials and medications may trigger allergic or sensitivity reactions. After lengthy appointments, jaw muscles may also be sore or tender. Holding one’s mouth open can, in a predisposed patient, precipitate a TMJ disorder. Gums and surrounding tissues may also be sensitive or painful during and/or after treatment. Although rare, it is also possible for the tongue, cheek or other oral tissues to be inadvertently abraded or lacerated (cut) during routine dental procedures. In some cases, sutures or additional treatment may be required. I understand that as part of dental treatment items including, but not limited to crowns, small dental instruments, drill components, etc. may be aspirated (inhaled into the respiratory system) or swallowed. This unusual situation may require a series of x-rays to be taken by a physician or hospital and may, in rare cases, require bronchoscopy or other procedures to ensure safe removal. I understand the need to disclose to the dentist any prescription drugs that are currently being taken or that have been taken in the past. I understand that taking the class of drugs prescribed for the prevention of osteoporosis, such as Fosamax, Boniva or Actonel, may result in complications of non-healing of the jaw bones following oral surgery or tooth extractions. I do voluntarily assume any and all reasonable medical/dental risks, including the substantial and significant risk of serious harm, if any, which may be associated with any phase of standard dental preventive and operative treatment procedures in hopes of obtaining the potential desired results, which may or may not be achieved, for my benefit or the benefit of my minor child or ward. I acknowledge that the nature and purpose of the foregoing procedures have been explained to me if necessary and I have been given the opportunity to ask questions.

Office Financial Policies and Federal Truth-In-Lending Statement

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon the reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time the services are performed.

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patients account. However, this dental office cannot render services on the assumption that our charges will be paid for by an insurance company.

A service charge at a fixed rate of 1.5% per month and 18% annually of the unpaid balance as of the last day of each month will be assessed and added to the balance on all accounts exceeding (30) thirty days from the date of service, unless previous written financial arrangements are made. I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me, or at my request, to my minor child, or ward by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended by the Doctor. In the event my account becomes delinquent, I agree to pay remaining balance plus, up to 50%, to whom a delinquent account is turned for collection, in addition to reasonable attorney fees and court costs where such legal services are necessary. I authorize the release of financially identifiable information concerning my account, including charges billed, payments made, and interest charges assessed, etc. to the dentist’s collections agency or collection attorney should collections procedures as described becomes necessary.

I grant permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form. I also agree to let this office leave messages concerning appointments and/or results on my answering machine or with a family member.

This agreement supersedes all prior agreements signed, including any and all mediation or mediation/arbitration agreements. I acknowledge that any prior mediation or mediation/arbitration agreements signed previously related to financial arrangements or quality care is null and void.

I authorize the doctor or his designees to release financially identifiable information and treatment descriptions and information, either electronically, by facsimile, or in paper form to my insurance carrier or any related entities that require such information to be submitted.

I acknowledge that I have received a copy of this office’s Privacy Policies, I agree to disclose to the Doctor names of any individuals with whom I authorize the Doctor to discuss my care.

I certify that I have answered all questions on both sides of this form accurately and to the best of my knowledge. I have read the above conditions of treatment and payment and agree to their content. I hereby agree to abide by the conditions outlined herein.

24 HOUR CANCELLATION POLICY: If your miss, cancel or change your appointment with less than 24 hours notice, you will be charged $50 per hour for a hygiene appointment and $75 per hour for a Doctor appointment.

General Dental Treatment Consent Form COVID-19 Pandemic

  1. I knowingly and willingly consent to dental treatment by Dr. Mark A. Baker and any designated associates and employees during the COVID-19 pandemic.
  2. I understand that Dr. Mark A. Baker is following CDC guidelines as far as treatment protocols and
    infection control.
  3. I am unaware of being a possible carrier or infected: I confirm that I have not tested positive for COVID-19
    in the last 30 days and that I am not presenting with any of the following symptoms of COVID-19:

    • Fever of 100.5 degrees Fahrenheit or 37 degrees Celsius or higher
    • Shortness of breath
    • Dry cough
    • Runny nose
    • Sore throat.
    • Diminished sense of taste and smell
  4. Contact with infected: I confirm that I have not knowingly been in close contact defined as 6 feet or less for a duration of fifteen minutes or more with someone who has tested positive for COVID-19 in the last 14
    days, or with anyone that has had the above stated symptoms in the last 14 days.
  5. Public travel: I confirm that I have not traveled outside of the United States in the past 14 days. I confirm
    that I have not traveled domestically by commercial airline, bus, or train within the last 14 days.
  6. I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not
    show symptoms yet are still highly contagious. It is impossible to determine who has it and who does not
    given the current limitations and availability in COVID-19 viral testing.
  7. Risk of transmission: I understand that due to the frequency of visits of other dental patients, characteristics
    of the virus, and the characteristics of dental procedures, that I may have an elevated risk of contracting the
    virus simply by being in a dental office, even though CDC and Utah Department of Health guidelines are
    being observed.
  8. INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the risks of
    contracting COVID-19 from the dental office and dental procedures. I reaffirm that I am not a carrier of
    COVID-19 nor infected with COVID-19 to the best of my knowledge. I do voluntarily assume any and all
    reasonable medical/dental risks, including the substantial and significant risk of serious harm, if any, which
    may be associated with any phase of my treatment as a result of the COVID-19 pandemic. I acknowledge
    that the nature and purpose of the dental procedures recommended have been explained to me if necessary
    and I have been given the opportunity to ask questions.

Client Rights and HIPAA Authorizations


The following specifies your rights about this authorization under the Health Insurance Portability and Accountability Act of 1996, as amended from time to time ("HIPAA").

  1. Tell your provider if you do not understand this authorization, and the provider will explain it to you.
  2. You have the right to revoke or cancel this authorization at any time, except: (a) to the extent information has already been shared based op this authorization; or (b) this authorization was obtained as a condition of obtaining insurance coverage. To revoke or cancel fthis authorization, you must submit your request in writing to provider at their office address.
  3. You may refuse to sign this authorization. Your refusal to sign will not affect your ability to obtain treatment, payment, enrollment or your eligibility for benefits. However, you may be required to complete this authorization form before receiving treatment if you have authorized your provider to disclose information about you to a third party. If you refuse to sign this authorization, and you have authorized your provider to disclose information about you to a third party, your provider has the right to decide not to treat you or accept you as a patient in their practice.
  4. Once the information about you leaves this office according to the terms of this authorization, this office has no control over how it will be used by the recipient. You need to be aware that at that point your information may no longer be protected by HIPAA. If the person or entity receiving this information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be disclosed to other individuals or institutions and no longer protected by these regulations.
  5. You may inspect or copy the protected dental information to be used or disclosed under this authorization. You do not have the right of access to the following protected dental information: psychotherapy notes, information compiled for legal proceedings, laboratory results to which the Clinical Laboratory Improvement Act ("CLIA") prohibits access, or information held by certain research laboratories. In addition, our provider my deny access if the provider reasonably believes access could cause harm to you or another individual. If access is denied, you may request to have a licensed health care professional for a second opinion at your expense.
  6. If this office initiated this authorization, you must receive a copy of the signed authorization.
  7. Special instructions for completing this authorization for the use and disclosure of Psychotherapy Notes. HIPAA provides special protections to certain medical records known as "Psychotherapy Notes." All Psychotherapy Notes recorded on any medium by a mental health professional (such as a psychologist or psychiatrist) must be kept by the author and filed separate from the rest of the client's medical records to maintain a higher standard of protection. "Psychotherapy Notes" are defined under HIPAA as notes recorded by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separate from the rest of the individual's medical records. Excluded from the "Psychotherapy Notes" definition are the following: (a) medication prescription and monitoring, (b) counseling session start and stop times, (c) the modalities and frequencies of treatment furnished, (d) the results of clinical tests, and (e) any summary of: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. Except for limited circumstances set forth in HIPAA, in order for a medical provider to release "Psychotherapy Notes" to a third party, the client who is the subject of the Psychotherapy Notes must sign this authorization to specifically allow for the release of Psychotherapy Notes. Such authorization must be separate from an authorization to release other dental records.
  8. You have a right to an accounting of the disclosures of your protected dental information by provider or its business associates. The maximum disclosure accounting period is the six years immediately preceding the accounting request. The provider is not required to provide an accounting for disclosures: (a) for treatment, payment, or dental care operations; (b) to you or your personal representative; (c) for notification of or to persons involved in an individual's dental care or payment for dental care, for disaster relief, or for facility directories; (d) pursuant to an authorization; (e) of a limited data set; (t) for national security or intelligence purposes; (g) to correctional institutions of law enforcement officials for certain purposes regarding inmates or individuals in lawful custody; or (h) incident to otherwise permitted or required uses or disclosures. Accounting for disclosures to dental oversight agencies and law enforcement officials must be temporarily suspended on their written representation that an accounting would likely impede their activities.

Notice of Privacy Practices

Premier Dental

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL/PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.


Summary:
By law, we are required to provide you with our Notice of Privacy Practices (NPP). This Notice describes how your medical information may be used and disclosed by us. It also tells you how you can obtain access to this information.
As a patient, you have the following rights:

  1. The right to inspect and copy your information
  2. The right to request corrections to your information
  3. The right to request that your information be restricted
  4. The right to request confidential communications
  5. The right to report of disclosures of your information
  6. The right to a paper copy of the Notice

We want to assure that your medical/protected health information is secure with us. This Notice contains information about how we will insure that your information remains private.
If you have any questions about this Notice, the name and phone number of our contact person is listed on this page.

Effective date of this Notice: 12/1/2016

Contact Person: Martha Horn (Office Manager)

Phone Number: 435-628-0621

Acknowledgement of Notice of Privacy Practices
"I hereby acknowledge that I have received a copy of the practice's NOTICE OF PRIVACY PRACTICES. I understand that if I have
questions or complaints regarding my privacy rights, that I may contact the person listed above. I further understand that the practice will offer me updates to this NOTICE OF PRIVACY PRACTICES should it be amended, modified or changed in any way.

Mark Baker, DMD

St George Dentist

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