Microsoft word - new patient documents.doc

Lawrence M. Bodenstein D.M.D.
Welcome To Our Office.
Do You Want Novocaine (local anesthetic) For Dental Treatment? Yes No
Have You Had any Previous Unfavorable Dental Experience? Yes No
Date of your last visit to the Dentist & reason for the visit
Previous Dentist and your reason for leaving Do you have or have you had any of the following?
Y N Recent Illness
>>> Please list any additional
Do you take any Bone Density medications? IE: Bisphosphonates? Yes / No
How do you take them, Orally, IV or IM?
Boniva, Fosamax, Zometa, Aredia, Actinel or Didronel? Other?
Do you have any Artificial Joints? Y N If so, please list
Are you allergic to or had any reactions to the following?
Y N Penicillin

Are you under the care of a physician? Y N For what reason?
List ALL medications you are taking
Do you take any kind of Blood Thinner including Aspirin? Y N
Are you required to Pre-medicate for dental treatment? Y N
WOMEN ONLY: Are you pregnant? Y N Are you nursing? Y N Are you taking birth control pills? Y N
Signature of Patient, Parent or Guardian:
Lawrence M. Bodenstein D.M.D.
Cosmetic & Family Dentistry
253 Boulevard, Suite 1
Hasbrouck Heights, N.J., 07604
FINANCIAL POLICY

Thank you for selecting us as your personal dental care team. To promote a long-term, mutually
satisfying relationship, we would like to explain our office policy regarding treatment, insurance,
appointments and fees. Please read this carefully and ask any questions or bring up any
concerns you may have BEFORE treatment is rendered. SUBMISSION TO TREATMENT
IMPLIES YOU CONSENT TO TERMS OF THIS AGREEMENT.
TREATMENT: You will find our entire office staff is dedicated to helping you improve your
dental health as efficiently as possible. Every effort will be made to make your appointment as
comfortable and pleasant as possible. Please feel free to discuss your treatment with the doctor
at any time.
INSURANCE: Even if our office is able to accept direct insurance assignment, the patient or
responsible party is still FULLY REPONSIBLE for the charges for the treatment rendered.
Your insurance MAY NOT COVER the services or may only PARTIALLY cover them and
any ESTIMATE given by this office is considered a GUIDELINE until insurance payment is
received and the patient’s account is reconciled. The office can make NO GUARANTEE of the
actual payment by your insurance company.
MISSED APPOINTMENTS: When we schedule your appointment, the time is reserved
exclusively for you. When you fail to notify us of your inability to keep the appointment,
another patient in need of dentistry is unable to receive treatment. We request that you give us at
least 24 hours notice when you realize that you cannot keep your appointment. When the
requested notice is not given , A fee of $50.00 per half hour scheduled will be charged. For those
whose schedules make it difficult to effectively plan ahead, we ask that you do not schedule an
appointment in advance, but rather call us the day you can come in and we will be happy to see
you then-provided the time is available.
PAYMENT IS DUE AT THE TIME OF SERVICE: We accept cash, personal checks,
Mastercard, Visa, Discover and American Express. In addition, we offer Care Credit for those requiring extended
payment plans. When insurance applies we will collect any deductible and estimated co-payment at the time of
service. We have payment options available for patients needing extensive dental work. Payment arrangements
must be approved before services are rendered. Please see the receptionist for more information.
PROSTHETICS: Crown, Dentures, Bridges, Etc. FAILURE BY PATIENT TO RETURN
FOR THE DELIVERY OF THESE ITEMS IS SUBJECT TO DOCTOR TIME AND LAB
FEES FOR TREATMENT PERFORMED.
SERVICE CHARGES:
1. MONTHY BILLING: A 1.5% charge will be applied every month to accounts
with balances outstanding 60 days or longer.
2. RETURNED CHECKS will result in a $25 fee charged to your account.
Replacement of funds must be paid by cash or credit card.
3. COLLECTION FEES incurred to collect unpaid balances as a result of failure
to conform to the terms of this agreement are the responsibility of the patient or
responsible party
Signature:
Patient/Parent or Legal Guardian if patient is a minor Lawrence M. Bodenstein D.M.D.
Cosmetic & Family Dentistry
253 Boulevard, Suite 1
Hasbrouck Heights, N.J., 07604
PATIENT CONSENT FOR USE AND DISCLOSURE
OF PROTECTED HEALTH INFORMATION

With my consent, Dr. Bodenstein or his representative, may use and disclose protected health information (PHI)
about me to carry out treatment, payment and healthcare operations (TPO). Please refer to Dr. Bodenstein’s
Notice of Privacy Practices for a more complete description of such uses and disclosures.
I have the right to review the Notice of Privacy Practices prior to signing this consent. Dr. Bodenstein reserves
the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be
obtained by forwarding a written request to Dr. Bodenstein at 253 Boulevard, Suite 1, Hasbrouck Heights, N.J.,
07604.
With my consent, Dr. Bodenstein or his representative may call my home or other designated location
and leave a message on voice mail or in person in reference to any items that assist the practice in
carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my
clinical care, including laboratory results among others.
With my consent, Dr. Bodenstein or his representative may mail to my home or other designated location any
items that assist the practice in carrying out TPO, such as appointment reminder cards and patient
statements.
With my consent, Dr. Bodenstein or his representative may e- mail to my home or other designated location any
items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I
have the right to request that Dr. Bodenstein or his representative restrict how it uses or discloses my PHI to carry
out TPO.
However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this
agreement. By signing this form, I am consenting to Dr. Bodenstein’s use and disclosure of my PHI to carry out
TPO.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance
upon my prior consent. If I do not sign this consent Dr. Bodenstein may decline to provide treatment to me.
______________________________
Signature of Patient or Legal Guardian
______________________________
___________________________________ Print Name of Patient or Legal Guardian Lawrence M. Bodenstein D.M.D.
Cosmetic & Family Dentistry
253 Boulevard, Suite 1
Hasbrouck Heights, N.J., 07604
Signature on File
I understand I am responsible for my bill. In the event my account is sent to a collection agency, I am also responsible for any charges incurred. I authorize use of this form on all of my Insurance forms. I authorize release of information to all my Insurance companies. I permit a copy of this authorization to be used in place of the original. I authorize payment to my Dentist. (Initial) I understand that if insurance is submitted on my behalf, I am still responsible for the full amount charged by this office, even if not paid by the Insurance Company.

Source: http://www.drbodenstein.com/listing/New_Patient_Documents.pdf