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General Dentist

Patients Name

Home Phone Number / Cell Phone Number

Email Address

Employed By

PhoneNo. / Ext

Occupation / Birthdate

Home Address

City / Zip

Social Security No.

If Student, Name of School

Name of Spouse(or parent if minor)

Employed by

Phone No. / Ext

Occupation / Birthdate

Address

City / Zip

Social Security No.

Has any family member been to this office before?

Yes No

If patient is a minor, who is legally responsible for the fee?

Address of Person Responsible

City / Zip

Phone No. / Ext

Dental Insurance

Name of Policyholder

Name of Insurance Company

Policy No. / Group No.

Dual Insurance?

Name of Policyholder

Name of Insurance Company

Policy No. / Group No.

Name of Relative

Phone Number

or Name of Friend

Phone Number

Financial Policy

Financial Policy
The mission of our office is to provide you with the highest quality dental care. Our service is based on a friendly, mutual, businesslike understanding between doctor and patient. We feel that misunderstandings can be minimized if financial policies are agreed upon at the beginning of treatment. The following statements are made to acquaint you with our policy:

a.There will be a consultation charge.

b.Fees quotes at the initial appointment will not increase; however, broken appointments or additional treatment may constitute an additional fee.

c.Our fee does not include the cost of a permanent restoration-to be done by your own dentist after your root canal has been completed.

d.All fees are payable at the time of treatment. We accept cash, personal check, all major credit cards and Carecredit. Upon credit approval, Carecredit offers both No-interest and Extended payment plans.

Please let us know if you have any concerns with regard to your financial responsibility.

Dental Insurance
All services rendered are charged directly to the patient who is then responsible for payment. If, however, we can verify insurance benefits, you will only be required to pay a deposit of one-half of the total fee on the day of treatment rather than pay in full. Your insurance company will pay a percentage of their own internal fee schedule. The insurance company’s allowed fees may be lower than our office fees. We will bill your insurance company at no charge. If the insurance company pays more than your balance, we will promptly reimburse you. We do understand that many patients have more than 50% coverage with their insurance; however we must make you aware that many times endodontic care is not covered with the same benefits as general dentistry . Unless we have prior authorization or proof of exact coverage, the minimum down will be one-half the total fee. Regardless of insurance coverage, any balance remaining in our office after 60 days is your responsibility. Therefore, if you have not heard from your insurance company in days, we suggest you contact them. If you have any questions regarding insurance billing or financial policy, fee free to discuss this with a Care Coordinator.

Cash accounts 30 days overdue and insurance accounts 75 days overdue will be charged a late fee of $25.00.

Please sign after reading:

Signature

Click to Sign

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

Please list any other drugs/materials that you are sensitive or allergic to:

Do you have trouble walking up one flight of stairs?

Yes No

Have you ever had an unfavorable reaction following dental treatment? Please discuss with doctor.

Yes No

Have you ever had excessive bleeding requiring special treatment? Please discuss with doctor.

Yes No

Are you pregnant or nursing?

Yes No

If pregnant, which month?

Consent and Information Form

Consent and Information Form
Regarding Health History, Endodontic (Root Canal) Therapy, Pre-medication, Local Anesthetic and Medication.

   It is the belief of this office that you should be informed about the treatment (therapy) and that you should give your consent before starting that treatment. The purpose of this form is to tell of the risks that may occur in the endodontic (root canal) treatment and the other treatment choices.

   Root canal treatment is done in order to retain a tooth (or teeth) which otherwise might need to be removed. Related dental surgery is done when needed.

   Risks of treatment are of two kinds: Those risks involved in general dental procedures and those risks specific to endodontic treatment.

   *PLEASE DO NOT BE ALARMED BY THE FOLLOWING INFORMATION. MOST COMPLICATIONS ARE QUITE RARE☺

RISKS OF DENTAL PROCEDURE IN GENERAL:
   Included (but not limited to) are complications resulting from the use of dental instruments, drugs, sedation, medicines, analgesics, anesthetics and injections. These complications include pain, infection, swelling, bleeding, sensitivity, numbness and tingling sensation in the lip, tongue, chin, gums, cheek and teeth, thrombophlebitis (inflammation to a vein), reaction to injections, change ion occlusion (biting), muscle cramps and spasms, temporomandibular (jaw) joint difficulty, loosening of teeth or restoration of teeth, injury to other tissues, referred pain to the ear, neck and head, nausea, vomiting, allergic reactions, itching, bruises, delayed healing, sinus complications, and further surgery. Medication and drugs may cause drowsiness and lack of awareness and coordination (which can be influenced by the use of alcohol and other drugs), thus it is advisable not to operate any vehicle or hazardous device, or work for twenty-four hours or until recovered from their effects. Antibiotics may effect birth control pills.

RISKS MORE SPECIFIC TO ENDODONTIC THERAPY:
   These risks include instruments broken within the root canals, perforations (extra openings) of the crown or root of the tooth, damage to bridges, existing fillings, crowns or porcelain veneers, loss of tooth structure in gaining access to canals and cracked teeth. During treatment complications may be discovered which make treatment impossible, or which may require dental surgery. These complications may include: blocked canals due to fillings, prior treatment, natural calcification, broken instruments; curved roots; periodontal disease (gum disease/pyorrhea); splits or fractures of the teeth. Surgical complications may occur which include numbness of the lip and/or chronic sinus problems.

THE OTHER TREATMENT CHOICES INCLUDE:
   No treatment, waiting for more definite development of symptoms, or having the tooth removed. Risks involved in these choices might include pain, swelling, infection, loss of tooth and infection to other areas. Treatment will be done in a manner to minimize or avoid risks as success cannot be guaranteed.
   Please understand that upon completion of root canal therapy in this office you will be directed to return to your general dentist for permanent restoration such as a crown, cap, jacket, only or filling. I, the undersigned, being the patient (parent or guardian of minor patient) consent to performing of the procedures decided upon to be necessary or advisable in the opinion of the doctor on the tooth or tissue as listed.

IF YOU HAVE ANY QUESTIONS, PLEASE WRITE THEM BELOW.

Root canal treatment is an attempt to retain a tooth which may otherwise require extraction. Although root canal therapy has a high degree of success, it cannot be guaranteed. Occasionally, a tooth which has had root canal therapy may require re-treatment, surgery or even extraction.

Patient/Parent Signature

Click to Sign

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

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

PATIENT RIGHTS
Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $25.00. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. {You must make your request in writing.} Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact Officer: Arlette Benoit-Scimeca

Telephone: (714) 774-8360 Fax: (714) 774-3212

E-mail: office@southerncalifornianendo.com

Address: 1801 W. Romneya Dr. Ste. 307 Anaheim, CA 92801

Acknowledgement of Receipt of Notice of Privacy Practices

Joseph H. Greiner DDS, A Dental Corporation
Acknowledgement of Receipt of Notice of Privacy Practices

Patient ID #

I hereby acknowledge that I have received a copy of Joseph H. Greiner DDS, A Dental Corporation ’s Notice of Privacy Practices. I understand that I have the right to refuse to sign this acknowledgement if I so choose.

Signature of Patient or Legal Representative

Click to Sign

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

Printed Name of Patient’s Representative (if applicable)

Relationship to Patient (if applicable)

Parent or guardian of unemancipated minor Court appointed guardian Executor or administrator of decedent's estate Power of Attorney

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Financial Policy

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Medical History

MEDICAL HISTORY

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Dental History

DENTAL HISTORY

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Consent and Information Form

Consent and Information Form

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NOTICE OF PRIVACY PRACTICES

Acknowledgement of Receipt of Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

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Registration

Registration

Financial Policy

Financial Policy

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Medical History

MEDICAL HISTORY

Are you sensitive or allergic to any of the following?

Do you have or have you had any of the following? (Please check YES or NO for every option)

Dental History

DENTAL HISTORY

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Consent and Information Form

Consent and Information Form

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NOTICE OF PRIVACY PRACTICES

Acknowledgement of Receipt of Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

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