Test Form Page Patient Information (*Skip to the next section if under 18) Patient Information (*Under 18) Dental Insurance Primary Insurance Secondary Insurance Getting To Know You Is another member of your family or relative a patient at our office? You were referred by: Your Former Address: Person To Contact For Emergency Closest Relative Not Living With You Account Information Person Financially Responsible For Account You Your Spouse Financial Policy Thank you for choosing Hilldale Dental as your dental health care provider . We are committed to your treatment being successful. The following is a statement of our Financial Policy which we require that you read and sign prior to treatment. A 5% courtesy adjustment will be applied for payment in full on or before the day of service by cash or check. Hilldale Dental is a preferred provider for most dental insurance plans. There may be a payment (copayment or estimated patient portion) due at your appointment based on your insurance plan. The patient's final financial responsibility can only be determined by the patient's insurance company and may be different than the payment collected on the date of service. Payment is due in full on the date of service for patients without insurance. The copayment is only an estimate of charges and may be found to be insufficient after review by your insurance company. Our practice does not guarantee that your insurance company will pay for the treatment you receive from our practice. Being familiar with the coverage and deductible of your insurance plan will help you to understand your financial responsibility. Your insurance policy is a contract between you and your insurance company. We accept cash, checks, Mastercard, Visa, or Discover. A fee of $30 will be charged for all returned checks. If the entire balance is not paid in full within 25 days of the monthly billing date, a 1% finance charge will be applied to your account. An appointment cancelled without 24 hour notice will result in a $25.00 fee. Financing options are available through PFC and Care Credit. Financing options are available through PFC and Care Credit. (Patient/Authorized Representative Signature) Consent of General Dental Care I hereby authorize the staff of Hilldale Dental Associates to employ such treatments and technical procedures as may be deemed necessary or advisable in the dental treatment of: I understand that this authorization will cover all aspects of routine dental care including administration of x-rays, photographic records, local anesthetics, sedative drugs and treatments including reparative dentistry (cleaning and scaling of teeth, fillings, root canal treatments, orthodontic care and the fitting of dentures, crowns and bridges), and minor surgical procedures (extract ions, gum surgery and biopsies). I authorize the release of any information relating to dental care and claims to my insurance company/companies. I hereby authorize payment directly to the Dentist of the Group Insurance Benefits otherwise payable to me. (Patient/Authorized Representative Signature) Insurance Filing Consent As a courtesy to you, we will file any insurance you request us to file based upon information you provide us but this is not a guarantee of payment. Your dental insurance or medical insurance is your financial responsibility. Regardless of what we might calculate as an estimate of your dental or medical benefit dollars; please be advised that you the patient are ultimately responsible for the total cost of your treatment and services. Dental or medical insurance is a contract between you and the insurance company. Allowed fees and usual customary fees have nothing to do with our actual charges. Our fees are based upon a combination of our costs, our time, and our constant dedication to providing our patients with the highest quality of dental care. Treatment is never based on what your insurance company will pay. Our billing department and your insurance company should process your claim within approximately 30 days, but if you have questions regarding a bill for services that you received, please call: 608-231-2424 Please sign below indicating that you have read the above statement and understand and agree to be bound by its contents. Thank you. (Patient/Authorized Representative Signature) Medical History Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. Are you under a physician's care now? If yes, who Have you ever been hospitalized or had a major operation? If yes, please explain Have you ever had a serious head or neck injury? If yes, please explain Are you taking any medications, pills, or drugs? If yes, please list Do you take, or have you taken, Phen-Fen or Redux? If yes, when Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? If yes, when Are you on a special diet? If yes, please explain Do you use tobacco? If yes, how often Medical History Do you have, or have you had, any of the following? AIDS/HIV Positive Yes No Alzheimer's Yes No Anaphylaxis Yes No Anemia Yes No Angina Yes No Arthritis/GoutYes No Artificial Heart ValveYes No Artificial JointYes No AsthmaYes No Blood DiseaseYes No Blood TransfusionYes No Breathing ProblemsYes No Bruise EasilyYes No CancerYes No ChemotherapyYes No Chest PainsYes No Cold Sores/Fever BlistersYes No Congenital Heart DisordYes No ConvulsionsYes No Cortisone MedicineYes No DiabetesYes No Drug AddictionYes No Easily WindedYes No EmphysemaYes No Epilepsy or SeizuresYes No Excessive BleedingYes No Excessive ThirstYes No Fainting/Dizziness Yes No Frequent CoughYes No Frequent DiarrheaYes No Frequent HeadachesYes No Genital HerpesYes No GlaucomaYes No Hay FeverYes No Heart Attack/FailureYes No Heart MurmurYes No Heart PacemakerYes No Heart Trouble/DiseaseYes No HemophiliaYes No Hepatitis AYes No Hepatitis B or cYes No HerpesYes No High Blood PressureYes No High CholesterolYes No Hives or RashYes No HypoglycemiaYes No Irregular HeartbeatYes No Kidney ProblemsYes No LeukemiaYes No Liver DiseaseYes No Low Blood PressureYes No Lung DiseaseYes No Mitral Valve ProlapseYes No OsteoporosisYes No Pain in Jaw JointsYes No Parathyroid DiseaseYes No Psychiatric CareYes No Radiation TreatmentsYes No Recent Weight LossYes No Renal DialysisYes No Rheumatic FeverYes No RheumatismYes No Scarlet FeverYes No ShinglesYes No Sickle Cell DiseaseYes No Sinus TroubleYes No Spina BifidaYes No Stomach Intest. Disease Yes No StrokeYes No Swelling of LimbsYes No Thyroid DiseaseYes No TonsillitisYes No TuberculosisYes No Tumors or GrowthsYes No UlcersYes No Venereal DiseaseYes No Yellow JaundiceYes No Have you ever had any serious illness not listed? If yes, 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 responsibmty to inform the dental office of any changes in medieal status. (Patient, Parent or Guardian Signature) Dental History Are your teeth sensitive to: Hot or Cold?Yes No Sweets?Yes No Biting or Chewing?Yes No Do you frequently get cold sores, blisters or-any other oral lesions?Yes No Do your gums bleed or hurt?Yes No Have your parents experienced gum disease or tooth loss?Yes No Have you noticed any loose teeth or change in your bite?Yes No Does food tend to become caught in between your teeth?Yes No Do you: Clench/grind your teeth?Yes No Hold foreign objects with your teeth?Yes No Mouth breathe?Yes No Have tired jaws?Yes No Snore or have any sleep disorders?Yes No Smoke tobacco?Yes No Chew tobacco?Yes No Have you experienced: Clicking or popping of the jaw?Yes No Pain (joint, ear, side of face)?Yes No Difficulty in chewing?Yes No Difficulty in opening or closing the mouth? Yes No Headaches, neck aches, or shoulder aches? Yes No Sore muscles in neck or shoulders?Yes No Have you ever had: Orthodontic treatment? Yes No Oral surgery?Yes No Periodontal treatment?Yes No A bite plate or mouth guard?Yes No A serious injury to the head or mouth?Yes No Are you satisfied with your teeth's appearance? Yes No Would you like to keep all of your teeth all of your life? Yes No Do you feel nervous about dental treatment? Yes No Have you ever had an upsetting dental experience? If so, please describe Is there anything else you would like us to know? Acknowledgement of Receipt of Notice of Privacy Practices You May Refuse to Sign This Acknowedgement* I, , have received a copy of this office's Notice of Privacy Practices. HIPAA 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 Dental Practice Covered By This Notice This Notice describes the privacy practices of Hilldale Dental ("Dental Practice"). "We" and "our" means the Dental Practice. "You" and "your" means our patient. How to Contact Us/ Our Privacy Official If you have any questions or would like further information about this Notice, you can either write to or call the Privacy Official for our Dental Practice: Dental Practice Name: Hilldale Dental - Dr. Fred Jaeger, DDS Privacy Official for Dental Practice: Fred Jaeger Dental Practice mailing address: 4414 Regent Street Madison, WI 53705 Dental Practice email address: email@example.com Dental Practice phone number: 608-231-2424 Information Covered By This Notice This Notice applies to health information about you that we create or receive and that identifies you. This Notice tells you about the ways we may use and disclose your health information. It also describes your rights and certain obligations we have with respect to your health information. We are required by law to: Maintain the privacy of your health information; give you this Notice of our legal duties and privacy practices with respect to that information; and abide by the terms of our Notice that is currently in effect. Our Use and Disclose of Your Health Information Without Your Written Authorization Common Reasons for Our Use and Disclosure of Patient Health Information Treatment. We will use your health information to provide you with dental treatment or services, such as cleaning or examining your teeth or performing dental procedures. We may disclose health information about you to dental specialists, physicians, or other health care professionals involved in your care. Payment. We may use and disclose your health information to obtain payment from health plans and insurers for the care that we provide to you. Health Care Operations. We may use and disclose health information about you in connection with health care operations necessary to run our practice, including review of our treatment and services, training, evaluating the performance of our staff and health care professionals, quality assurance, financial or billing audits, legal matters, and business planning and development. Appointment Reminders. We may use or disclose your health information when contacting you to remind you of a dental appointment. We may contact you by using a postcard, letter, voicemail, or email. Treatment Alternatives and Health-Related Benefits and Services. We may use and disclose your health information to tell you about treatment options or alternatives or health related benefits and services that may be of interest to you. Disclosure to Family Members and Friends.We may disclose your health information to a family member or friend who is involved with your care or payment for your care if you do not object or, if you are not present, we believe it is in your best interest to do so. Less Common Reasons for Use and Disclosure of Patient Health Information The following uses and disclosures occur infrequently and may never apply to you. Disclosures Required by Law. We may use or disclose patient health information to the extent we are required by law to do so. For example, we are required to disclose patient health information to the U.S. Department of Health and Human Services so that it can investigate complaints or determine our compliance with HIPAA. Public Health Activities. We may disclose patient health information for public health activities and purposes, which include: preventing or controlling disease, injury or disability; reporting births or deaths; reporting child abuse or neglect; reporting adverse reactions to medications or foods; reporting product defects; enabling product recalls; and notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. Victims of Abuse, Neglect or Domestic Violence. We may disclose health information to the appropriate government authority about a patient whom we believe is a victim of abuse, neglect or domestic violence. Health Oversight Activities. We may disclose patient health information to a health oversight agency for activities necessary for the government to provide appropriate oversight of the health care system, certain government benefit programs, and compliance with certain civil rights laws. Lawsuits and Legal Actions. We may disclose patient health information in response to (i) a court or administrative order or (ii) a subpoena, discovery request, or other lawful process that is not ordered by a court if efforts have been made to notify the patient or to obtain an order protecting the information requested. Law Enforcement Purposes. We may disclose patient health information to a law enforcement official for a law enforcement purposes, such as to identify or locate a suspect, material witness or missing person or to alert law enforcement of a crime. Coroners, Medical Examiners and Funeral Directors. We may disclose patient health information to a coroner, medical examiner or funeral director to allow them to carry out their duties. Organ, Eye and Tissue Donation. We may use or disclose patient health information to organ procurement organizations or others that obtain, bank or transplant cadaveric organs, eyes or tissue for donation and transplant. Research Purposes. We may use or disclose patient health information for research purposes pursuant to patient authorization waiver approval by an Institutional Review Board or Privacy Board. Serious Threat to Health or Safety. We may use or disclose patient health information if we believe it is necessary to do so to prevent or lessen a serious threat to anyone's health or safety. Specialized Government Functions. We may disclose patient health information to the military (domestic or foreign) about its members or veterans, for national security and protective services for the President or other heads of state, to the government for security clearance reviews, and to a jail or prison about its inmates. Workers' Compensation. We may disclose patient health information to comply with workers' compensation laws or similar programs that provide benefits for work-related injuries or illness. Your Written Authorization for Any Other Use or Disclosure of Your Health Information We will make other uses and disclosures of health information not discussed in this Notice only with your written authorization. You may revoke that authorization at any time in writing. Upon receipt of the written revocation, we will stop using or disclosing your health information for the reasons covered by the authorization going forward. Your Rights with Respect to Your Health Information You have the following rights with respect to certain health information that we have about you (information in a Designated Record Set as defined by HIPAA). To exercise any of these rights, you must submit a written request to our Privacy Official listed on the first page of this Notice. Access. You may request to review or request a copy of your health information. We may deny your request under certain circumstances. You will receive written notice of a denial and can appeal it. We will provide a copy of your health information in a format you request if it is readily producible. If not readily producible, we will provide it in a hard copy format or other format that is mutually agreeable. If your health information is included in an Electronic Health Record, you have the right to obtain a copy of it in an electronic format and to direct us to send it to the person or entity you designate in an electronic format. We may charge a reasonable fee to cover our cost to provide you with copies of your health information. Amend. If you believe that your health information is incorrect or incomplete, you may request that we amend it. We may deny your request under certain circumstances. You will receive written notice of a denial and can file a statement of disagreement that will be included with your health information that you believe is incorrect or incomplete. Restrict Use and Disclosure. You may request that we restrict uses of your health information to carry out treatment, payment, or health care operations or to your family member or friend involved in your care or the payment for your care. We may not (and are not required to) agree to your requested restrictions, with one exception. If you pay out of your pocket in full for a service you receive from us and you request that we not submit the claim for this service to your health insurer or health plan for reimbursement, we must honor that request. Confidential Communications. Alternative Means, Alternative Locations. You may request to receive communications of health information by alternative means or at an alternative location. We will accommodate a request if it is reasonable and you indicate that communication by regular means could endanger you. When you submit a written request to the Privacy Official listed on the first page of this Notice, you need to provide an alternative method of contact or alternative address and indicate how payment for services will be handled. Accounting of Disclosures. You have a right to receive an accounting of disclosures of your health information for the six years prior to the date that the accounting is requested except for disclosures to carry out treatment, payment, health care operations (and certain other exceptions as provided by HIPM). The first accounting we provide in any 12-month period will be without charge to you. We will charge a reasonable fee to cover the cost for each subsequent request for an accounting within the same 12-month period. We will notify you in advance of this fee and you may choose to modify or withdraw your request at that time. Receive a Paper Copy of this Notice. You have the right to a paper copy of this Notice. You may ask us to give you a paper copy of the Notice at any time (even if you have agreed to receive the Notice electronically). To obtain a paper copy, ask the Privacy Official. We Have the Right to Change Our Privacy Practices and This Notice We reserve the right to change the terms of this Notice at any time. Any change will apply to the health information we have about you or create or receive in the future. We will promptly revise the Notice when there is a material change to the uses or disclosures, individual's rights. our legal duties. or other privacy practices discussed in this Notice. We will post the revised Notice on our website (if applicable) and in our office and will provide a copy of it to you on request. The effective date of this Notice (including any updates) is in the top right-hand corner of the Notice. To Make Privacy Complaints If you have any complaints about your privacy rights or how your health information has been used or disclosed, you may file a complaint with us by contacting our Privacy Official listed on the first page of this Notice. You may also file a written complaint with the U.S. Department of Health and Human Services Office for Civil Rights. The privacy of your health information is important to us. We will not retaliate against you in any way if you choose to file a complaint. Submit Secure Form Your request has been sent -- we will be in contact with you shortly. There was an error! Please phone our office.