As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Patient Information

Dental Information

Medical Information

Allergies Please mark "Yes" if you are allergic to (or have had a reaction to) the following.

Please mark "Yes" if you have (or have had) any of the following diseases or problems.

Pharmacy Information

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

General Information

Consent & Notice of Privacy Practices

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operation.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information.

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.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting us by phone or email.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us a written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance of this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Authorization for use or Disclosure of Protected Health Information
(Required by the Health Insurance Portability and Accountability Act)

I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. Unless otherwise revoked, this authorization shall be in force and effect indefinitely until changes are made by the patient.

Signature

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

General Information

Primary Dental Insurance

Secondary Dental Insurance

If I am entitled to benefits under Medicare, Medicaid, or any insurance policy or other health benefit plan (covering me or anyone legally responsible for me), in consideration of services provided to me, I assign, transfer and convey the benefits payable under such program, policy or plan for services rendered to me. I authorize payment of these benefits directly, with such benefits being applied to my bill. I understand and acknowledge that this assignment does not relieve me of financial responsibility for charges incurred by me or anyone on my behalf, and I hereby acknowledge responsibility for and agree pay charges not paid under this assignment, including any coinsurance amounts, deductibles, Durable Medical Equipment, and any charges for service deemed to be non-covered, not pre-certified, or not pre-authorized by my insurance plan.

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

General Information

Patient Screening

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Thank you for choosing us as your Dental Care Provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. All patients must read and sign this form prior to seeing the doctor.

DENTAL INSURANCE: Our office will gladly work with you to help get the maximum benefit available to you. Most dental insurance plans do not cover 100% of your treatment cost. Therefore, you will be expected to pay your deductible and your estimated co-payment on the day that the services are rendered. We will gladly file your insurance claim as a courtesy. Many variables exist from carrier to carrier (i.e., restrictions): therefore, we cannot guarantee any estimated charges. Your policy and benefits are an agreement between you and the insurance company so ultimately you are responsible for all charges. Please know that we will do everything possible to see that you receive the full benefits from your insurance company. If for some reason your insurance company has not paid their estimated portion within 60 days from the start of treatment, you are responsible for payment in full at that time. Treatment could be altered if your dental needs change. The patient will be notified of any change(s) in treatment. We will gladly file all dental claims for any given treatment, but we are not party to any insurance programs or contracts. The balance is YOUR RESPONSIBILITY whether your insurance company pays for your treatment or not. It is your responsibility to inform us of any changes in your insurance coverage.

REGARDING INSURANCE PLANS WHERE WE ARE A PARTICIPATING PROVIDER: All ESTIMATED portions and deductibles are due prior to treatment. In the event your insurance coverage changes to a plan where are a non-participating provider, please refer to the above paragraph. You are responsible for advising this office if you have a change in your insurance coverage PRIOR to your scheduled appointment.

TREATMENT PLAN ESTIMATES: We prepare TREATMENT PLAN ESTIMATES so that patients can understand their estimated cost of recommended restorative treatment prior to start. The Estimate is a good-faith attempt to predict the cost of your treatment based on the known facts when the estimate is made. As your treatment progresses, your dentist may determine in consultation with you that additional or a change in treatment may be necessary and that would change the estimated cost.

MISSED / BROKEN APPOINTMENTS: We respectfully ask that you give us a minimum 48-hour notice to cancel or reschedule your reserved appointment. We kindly ask you to reschedule hygiene visits within 30 days of your recommended recall schedule. A broken appointment is defined as one for which the patient failed to show-up or to cancel an appointment with less than 24 hours’ notice. As of January 1, 2022, this office will charge for broken appointments at a rate of $75 per hour. All charges for broken appointments must be paid before any other appointments will be scheduled. All adult patients are required to sign for minors/dependents and themselves.

ASSIGNMENT OF INSURANCE BENEFITS: I understand that services rendered to me by Dr. Melinda Marino, DDS, Associate Dentist, and/or Hygienist (collectively labeled as “Provider”) are my financial responsibility and that the Provider will bill my insurance company as a courtesy. I authorize my insurance company to pay my benefits directly to Provider. I understand that I will be fully responsible for any outstanding balance on my account. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEIFTS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above-mentioned assignee, and I have agreed to pay, in a current manner, any balance of professional service charges over and above this insurance payment.

I have been given the opportunity to pay my estimated deductible and co-insurance at the time of service. I have chosen to assign the benefits, knowing that the claim must be paid within all state or federal prompt payment guidelines. I will provide all relevant and accurate information to facilitate the prompt payment of the claim by 25 days (electronically filed) or 45 days (paper mailed).

I authorize the Provider to release any information necessary to adjudicate the claim and understand that there might be associated costs for providing information beyond what is necessary for the adjudication of a clean claim. I also authorize the Provider to initiate a complaint to the insurance commissioner for any reason on my behalf.

I understand that should my insurance company send payments directly to me; I will forward the payment on to the Provider within 48 hours. I agree that if I fail to send the payment to the Provider, and they are forced to proceed with the collections process, I will be responsible for any cost incurred by the office to retrieve their monies. In the event the patient receives any check, draft, or other payment subject to this agreement, I will immediately deliver said check, draft, or other payment to Provider. Any violations of this agreement will, at Provider’s election, terminate Patient charge privileges with Provider, as well as bring any balance owed by Patient to Provider immediately due and payable.

I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payers and/or healthcare practitioners.

I grant my permission to your or your assignee, to telephone me at home, my work, or my cell phone to discuss matters related to this form.

I have read the above conditions of treatment and payment and agree to the contents.

Signature

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.