Valley Endodontics, LTD

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Patient Information

Patient's Name

Preferred Name

Patient's Street Address

Date of Birth / Home Phone / Cell Phone

Minor Patients or those under guardianship

Person Financially Repsonsible For Dental Treatment if Different From Above

Name

Address

Phone # / Date of Brith

Is dental problem do to an accidental injury

Yes No

Date

Description

Referring Dentist

Family Physician

Location

Who should be contacted in case of emergency?

Relationship / Telephone

Insurance Information

Do you have dental insurance?

Yes No

Name of Insurance Company

Insured Employee Name

Group # / ID #

D.O.B.

Do you have a second dental insurance?

Yes No

Name of Insurance Co.

Insured Employee Name

Group # / ID #

D.O.B.

Employment Information

Patient's Employer

Occupation

Business Phone

Spouse Information needed for Wisconsin Marital Property Act

Spouse's Name

Spouse's Address

Spouse's DOB

Cell #

Spouse's Employer

FINANCIAL POLICY

If you do not have dental insurance coverage: a minimum payment of 50% of your fee is due at the time of treatment. The remaining balance is due within 30 days of the completion of your treatment. We accept payments by cash, check, VISA, MC, Discover, Amex and CareCredit. By paying in full with cash or check, an additional 5% savings will be given. If you are scheduled for a consultation, the fee is due in full at time of service.

We are Out of Network for all insurance plans, including Medicare insurance plans.

If you have dental insurance coverage: we will process your initial insurance claim for professional services rendered if you timely provide us with the appropriate information and authorization. All professional fees generated at our office are your responsibility. We will specify a portion of the fee to be paid at the time of service. Any balance not paid by the dental insurance is due and payable in full within 30 days of insurance payment. In the event that it is your insurance company’s policy to send payments directly to subscribers/patient, your credit card will be securely stored and payment will be processed when due. The ultimate and final responsibility for payment rests entirely with the patient/guarantor regardless of insurance plan coverage or lack of coverage.

I authorize release of any personal dental/medical information relating to my insurance claim to my dental/medical insurance company. I hereby authorize payment directly to Valley Endodontics, Ltd. of the group insurance benefits otherwise payable to me.

All patients:
I understand that I am responsible for all costs of dental treatment including any banking fees for NSF checks and all cost associated with collection procedures, including attorney fees.

Patient/Gurantor Signature

Click to Sign

Date:-------------

I certify that this Medical History is accurate, complete, and current. I understand that my health and the health of others depend on the accuracy and completeness of this information.

Signature

Click to Sign

Date:-------------

Valley Endodontics LTD.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

CONSENT FOR USE & DISCLOSURE OF HEALTH INFORMATION

Purpose of Consent: By signing this form, you will acknowledge receipt of this office's Notice of Privacy Practices and you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. You may refuse to sign this consent.

TO THE INDIVIDUAL: Please read the following and complete the information requested.

Effect of Declining Consent: This consent is a condition of your treatment by us. If you decide not to sign this consent, we may decline to treat you.

Privacy Practices Notice: You have the right to read our Privacy Practices Notice before you decide whether to sign this consent. Our Notice provides a description of our treatment, payment activities, and health care operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this consent. We encourage you to read it carefully and completely before signing this consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

Contact Office:

Valley Endodontics, Ltd.
1100 N. Lynndale Drive
Telephone: (920) 731-4484

Appleton, WI 54914
Fax: (920) 731-2889

E-mail: referrals@valleyendo.com

INDIVIDUAL'S SIGNATURE

I, have had full opportunity to read and consider the contents of this consent. I understand that, by signing this form, I am confirming that I have received a copy of this office's Notice of Privacy Practices and am giving my written permission for the disclosure of my protected health information, as described in this form.

Signature

Click to Sign

Date:-------------

If this consent is signed by a personal representative on behalf of the individual, complete the following:

Personal Representative's Name

Relationship to Individual:

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Valley Endodontics, LTD

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Registration - Appleton

Patient Information

Insurance Information

Insurance Information

Employment Information

Spouse Information needed for Wisconsin Marital Property Act

Financial Policy

FINANCIAL POLICY

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Health History

Health History

Do you or have you ever had:

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Conclusion

Valley Endodontics LTD.

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Valley Endodontics, LTD

Main Header

Registration - Appleton

Patient Information

Insurance Information

Insurance Information

Employment Information

Spouse Information needed for Wisconsin Marital Property Act

Financial Policy

FINANCIAL POLICY

Click to Sign

Health History

Health History

Do you or have you ever had:

Click to Sign

Conclusion

Valley Endodontics LTD.

Click to Sign

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Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

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