Thank you for visiting Rick Larson, D.D.S. We want your visit to be pleasant and comfortable. Please help us by completing this form
Personal Details
Title:
First Name:
Last Name:
Middle Initial:
Birthdate:
Gender:
Address:
City:
State:
Zip Code:
Email Address:
Occupation:
Patient Employer/School:
Employer/School Address:
Employer/School Phone:
How did you hear about our office?
How do we contact you?
Home Phone:
Work Phone:
Ext:
Alt. Phone:
Spouse's Work:
Best time and place to reach you
IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)
Name:
Relationship:
Home Phone:
Work Phone:
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Spouse Information
Spouse Name:
Birthdate
Social Security Number:
Spouse's Employer:
Who may we thank for referring you?:
Dental Insurance Information
Who is responsible for this account?:
Relationship to Patient:
Insurance Company:
Group #:
Employee Name :
Employer Name :
Insurance Company Name:
Insurance Co.Phone:
Subscriber Name:
Subscriber ID#:
Subscriber DOB:
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Additional Insurance Information
Subscriber's Name:
Birthdate:
Social Security Number:
Relationship to Patient:
Insurance Company:
Group #:
company's phone number:
ASSIGNMENT AND RELEASE
I certify that I, and/or my dependent(s), have insurance coverage with and assign directly to Dr.
all insurance benefits, if any otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
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Name of Patient, Parent, Guardian or Personal Representative:
Relationship to Patient
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Physician's Name:
Date of last visit:
Place a mark on 'Yes' or 'No' to indicate if you had any of the following
Pharmacy Name:
Phone Number
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.
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Reason for today's visit:
Former dentist:
City:
State:
Date of last dental visit:
Date of last X-rays:
Place a mark on 'Yes' or 'No' to indicate if you had any of the following
How often do you floss?
How often do you brush?
X-RAY CONSENT FORM
Patient Name
During your examination, the doctor may feel that x-rays/pictures will be needed in order to diagnose
your condition. We would like to make you aware that x-rays may be required in order to administer
treatment. In order to perform x-rays/pictures on any patient our office requires the patients consent
for such tests to be performed.
I understand that my doctor may need x-rays/pictures in order to diagnose my condition. I give my permission of all needed diagnostic tests and for such items be used for purposes of research, education or publication in professional journals.
I understand that my condition may require my doctor to take x-rays to further diagnose my symptoms. I choose to not have any x-rays/pictures at this time and release my doctor of all liabilities.
The information on this page is correct to the best of my knowledge.
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I understand that if I am pregnant and have x-rays taken which expose my lower torso to radiation, it is
possible to injure the fetus.
I have been advised that ten (10) days following onset of menstrual period are generally considered to
be safe for x-ray exams.
With those factors in mind, I am advising my doctor that:
The information on this page is correct to the best of my knowledge.
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Patient Acknowledgement and Consent Form
Effective April 14, 2003, the new federal law known as the Health Insurance Portability and Accountability Act of 1996 ('HIPAA') requires that this office comply with certain rules regarding the maintenance of the privacy of yourInformation that we have collected and will collect in the future.
To comply with one of the HIPAA requirements,Ricky L Larson DDS PLLC is providing you with a copy of our Notice of Privacy Practices. This Notice of Privacy Practices contains the information that HIPAA requires us to disclose regarding our privacy practices. Existing Texas law requires(In addition to our
attempt to obtain your written acknowledgement,discussed above) us to first obtain your written consent prior to disclosing any of your information except for our disclosures in connection with:a defense to a claim challenging our professional competence; a review of the entity's functions;a claim for payment of fees; a third party payer's examination of our records;a court order as part of a criminal investigation; an identification of a dead body;a licensure investigation; or a child abuse/neglect investigation
In some instances,it may be necessary for us to make disclosures of your informationin connection with your treatment. For example,we may make a referralto or consult with another covered entity for testing or otherwise makedisclosures of your informationin connection with providing or coordinating your treatment.
Please sign this form below under the heading "acknowledgment" to acknowledge that you have today received a copy of our Notice of Privacy Practices.
I acknowledge that I have today received a copy of the Notice of Privacy Practices.
Patient Name
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Patient Consent & Authorization
Please sign this form below under the heading "Consent" to consent to our disclosures of your information that we deem necessary inorder to provide you with proper treatment.
I consent to your disclosures of my information, which you deem are necessary in connection with my treatment
Communication with laboratories or other specialists for any medical treatment, consultations, and educational purposes or for any other purpose deemed appropriate by Ricky L Larson DDS PLLC.
Patient Name
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OFFICE POLICIES
We would like to welcome you to our office, and are happy you have chosen us for your dental care. Our goal is to provide you with the best possible care available. In order to meet this goal, we need your assistance and understanding of our office policies. Our Financial Policy is a necessary part of assuring the financial resources needed to maintain this vital health care facility for our patients.
Insurance Companies
We are here to help answer any questions
you may have regarding your insurance coverage and payments. However, your insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract. Most companies base insurance payments on a Usual and Customary Rate (UCR). Our fees generally fall within the UCR range; unfortunately, some insurance companies reimburse on a fee schedule, which may bear no relationship to the current standard and cost of care in this area. You will be responsible for our charges regardless of the company's arbitrary determination of the UCR. As a courtesy to our patients, we will file your claims directly to your primary insurance carrier. If you have secondary insurance,we will be happy to provide you with the necessary information for you to file.
Financial Responsibility
Full payment of services is due at the time of your visit. lf you have a dental insurance plan, co-payment and deductible amounts will be collected at the time of the visit. ln the event that it is an uncovered procedure, or if your maximum has been met for the year, the full amount will be due at your visit. We accept cash, checks, Visa, MasterCard, American Express and Discover.
We also offer Care Credit for financing options.
Broken Appointments
Thank you for choosing us as your dental health care provider. We believe it is important that our patients fully understand our financial and office policies, so we may concentrate on you and
your dental needs. It is your responsibility to notify us of any changes in your account status (i.e.
changes of address, work and home phone numbers and insurance infonnation.) Our business office is available during regular business hours, and we welcome any questions you may have regarding our policies.
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I have read the above, and I understand and agree to this financial policy.
PATIENT AUTHORIZATION TO RELEASE RECORDS
I authorize
Dr.
to release information regarding my dental health, or the dental health of my child (ren). I understand that the above information and any current x-rays will be transferred to Dr. Rick Larson at my request.
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