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COVID-19 Pandemic Dental Treatment Notice and Acknowledgement of Risk Form

The World Health Organization has characterized the COVID-19 virus, also known as “Coronavirus,” as a pandemic. Our practice wants to ensure you are aware of the risks of exposure to COVID-19 associated with receiving treatment during this pandemic.

COVID-19 is highly contagious and has a long incubation period. You or your healthcare providers may have the virus, not show symptoms and yet still be highly contagious. COVID-19 can result in a life-threatening respiratory disease in some patients. You may be exposed to COVID-19 at any time or in any place. Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office.

Dental procedures can create fine water spray or “aerosols” which may remain in the air for several minutes to hours. These aerosols may contain the COVID-19 virus and may create a risk of COVID-19 exposure. You cannot wear a protective mask over your mouth to reduce exposure during treatment as your healthcare providers need access to your mouth to render care. This leaves you vulnerable to COVID-19 transmission while receiving dental treatment.

To provide a safe environment for our patients and staff, this practice follows the applicable state and federal regulations and protocols for infection control, universal personal protection, and disinfection. However, due to the nature of the procedures we provide, it may not be possible to maintain social distancing between patients, doctors, and staff at all times.

Patient Acknowledgement
I acknowledge that I have read the Notice above and that I understand and accept that there is an increased risk of COVID-19 exposure with treatment during the pandemic.
I understand and accept the increased risk of COVID-19 exposure with treatment at this office.
I also acknowledge that I could, or may have, exposure to COVID-19 from outside this office and unrelated to my visit here.

Signature of patient (Parent or Guardian if Minor)

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

Who will be responsible for your account?

Self Spouse Father Mother Other

Who will be responsible for your account

Name

Birth Date / Age / Soc. Sec. #

Tel. / Cell

Email / Driver's License

Address

City / State / Zip

Employer / Phone

Spouse or other guarantor information (if different from above)

Name

Birth Date / Soc. Sec. #

Relation / Tel.

Address

City / State / Zip

Employer / Business Name

Are you a student?

Full-time Part-time Not a student

School Information

School Name

School Address

City / State / Zip

Primary Dental Insurance Information

Employer / Business

Business Address

City / State / Zip

Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Ins. Company Address

City / State / Zip

Phone Number

Group

Insured Party Name

Relation / Birth Date

Insured Party Sex

Male Female

Phone / Social Security #

Insured Party Address

City / State / Zip

Primary Medical Insurance Information

Employer / Business

Business Address

City / State / Zip

Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Ins. Company Address

City / State / Zip

Phone Number

Group

Insured Party Name

Relation / Birth Date

Insured Party Sex

Male Female

Phone / Social Security #

Insured Party Address

City / State / Zip

Do you have secondary dental or medical insurance?

Yes No

Secondary Dental Insurance Information

Employer / Business

Business Address

City / State / Zip

Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Ins. Company Address

City / State / Zip

Phone Number

Group

Insured Party Name

Relation / Birth Date

Insured Party Sex

Male Female

Phone / Social Security #

Insured Party Address

City / State / Zip

Secondary Medical Insurance Information

Employer / Business

Business Address

City / State / Zip

Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Ins. Company Address

City / State / Zip

Phone Number

Group

Insured Party Name

Relation / Birth Date

Insured Party Sex

Male Female

Phone / Social Security #

Insured Party Address

City / State / Zip

Are you taking any kind of medication, drug, pills?

Yes No

Please list any medications you are currently taking

Medication #1

Medication #2

Medication #3

Medication #4

Medication #5

Medication #6

Medication #7

Medication #8

Medication #9

Medication #10

Medication #11

Medication #12

Medication #13

Medication #14

Medication #15

Medication #16

Medication #17

Medication #18

Medication #19

Medication #20

Please list any other medications or antibiotics you are allergic to

Medication / Antibiotic Allergy #1

Medication / Antibiotic Allergy #2

Medication / Antibiotic Allergy #3

Medication / Antibiotic Allergy #4

Medication / Antibiotic Allergy #5

Medication / Antibiotic Allergy #6

Medication / Antibiotic Allergy #7

Medication / Antibiotic Allergy #8

Medication / Antibiotic Allergy #9

Medication / Antibiotic Allergy #10

Is there a FAMILY history of

Cancer

Yes No

Diabetes

Yes No

Heart Disease

Yes No

Anesthesia Problems

Yes No

This section is for women only

Is there a possibility of pregnancy?

Yes No

Expected delivery date

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

Note: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding additional methods of birth control.

Is this visit related to an accident?

Yes No

If Yes, What type?

Automobile

Work related

Other

Date of Injury

Insurance Company / Claim #

Attorney / Adjustor & Phone

Verification

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

Signature of patient (Parent or Guardian if Minor)

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

FEES & PAYMENTS

We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.

Signature of patient (Parent or Guardian if Minor)

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

This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

Signature of patient: (Parent or Guardian if Minor)

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

AUTHORIZATION

I authorize my surgeon and his / her designated staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x–rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers. I permit messages to be left on my phone and / or mobile phone concerning my appointment

I permit the office to communicate with me via text message on my cell phone.

Yes No

Signature of patient (Parent or Guardian if Minor)

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

I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

Signature of patient (Parent or Guardian if Minor)

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

FINANCIAL POLICY

• As a courtesy to you, we will submit claims to your insurance carrier. If ample time is given, we will provide an insurance estimate to you for services over $1,000.00; however it is not a guarantee that your insurance will pay exactly as estimated. Your insurance coverage may be subject to limitations, exclusions, waiting periods, frequency, age restrictions, deductible and maximums which are the patient’s responsibility.

• Payment for services is due at the time of service. Payments may be made using cash or credit cards. We cannot accept a personal check for amounts over$1,000.00. For check payments for over $1,000.00 we require a certified bank check. We also participate with CareCredit.

• Payment is due in full at the time of service for biopsies, iCATs, and any service under $500.

• Services over $500 will require a 50% deposit at the time of the procedure. Once the dental claim has been processed, if there is a patient overpayment, a check will be issued for the amount. If there is a balance outstanding, the patient will receive a statement and will be required to submit payment within 30 days.

• There is a $100 cancelation fee if you don’t cancel your appointment 48 business hours in advance.

All charges incurred are your responsibility, regardless of your insurance coverage. We must emphasis that our relationship is with you, the patient, not your insurance company. I have read and understand the Financial Policy.

Signature of Patient (or Parent of Minor)

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

PATIENT CONSENT FORM AND ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Dr. Fabian LaTocha

PATIENT CONSENT FORM AND ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to review our notice before signing this consent. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy by contacting our Business 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 are bound by our 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, including leaving messages on your home, cell and/or work answering machines. You have the right to revoke this consent, in writing, except where we have already made disclosure in reliance on your prior consent.

Please complete below: I give authorization to the doctors and staff of Oral & Maxillofacial Surgeons of Lake County to discuss my medical and/or financial information with the following people:

Name

Relationship

Phone

I understand that photographs, videotapes, digital or other images may be recorded to document my care, and I consent to this. I understand that Dr. Fabian LaTocha will retain the ownership rights to these photographs, videotapes, digital or other images, but that I will be allowed access to view them and obtain copies. I understand that these images will be stored in a secure manner that will protect my privacy and that they will be kept for the period of time required by law as outlined in Dr. LaTocha’s policy. Images that identify me will be released and/or used outside the office only upon written authorization from my legal representative or me.

In signing this form, I acknowledge having reviewed/received a copy of this office’s Notice of Privacy Practices and also give my consent to the above.

Name:

Signature

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

202 S. Greenleaf St., Ste. A, Gurnee, Illinois 60031 Phone 847-623-2830 Fax 847-623-1534

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Covid-19 Questionnaire

Patient Disclosures

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COVID-19 Pandemic Dental Treatment Notice and Acknowledgement of Risk Form

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Demographic Information

Patient information

Who will be responsible for your account

Spouse or other guarantor information (if different from above)

Insurance Information

General Insurance Information

School Information

Primary Dental Insurance Information

Primary Medical Insurance Information

Secondary Dental Insurance Information

Secondary Medical Insurance Information

Health History

Health History

Have you ever had or do you currently have...

Medications / Allergies

Medications (Are you now taking...)

Please list any medications you are currently taking

Are you allergic to, or had a reaction to:

Column2

Please list any other medications or antibiotics you are allergic to

Is there a FAMILY history of

This section is for women only

Is this visit related to an accident?

Verification

Verification

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Click to Sign

Click to Sign

Click to Sign

Financial Policy

FINANCIAL POLICY

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Patient Consent and Acknowledgement of Privacy Practices

PATIENT CONSENT FORM AND ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

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