NEW PATIENT INFORMATION FORM (2) in Rancho Mirage, CA

New Patient Information Form(2)

Step 1 of 15

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Welcome to Cros Dental

Chart#:

Name(Required)

Last First MI Preferred Name

Title:

Gender

Male

Female

Family Status

Married

Sinlge

Child

Other

Birth Date

SS#:

Prev. Visit:

Email(Required)

Best time to call:

Phone

Mobile

Work

Ext

Fax

Other

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

This only needs to be filled out if the insurance subscriber is other than the patient, or if the patient is under 18.

Name of Insured:(Required)

Last First MI

Insured's Birth Date:

ID#:

Group#:

Insured's Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Insured's Employer Name:

Employer Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Patient's relationship to insured:

Self Spouse

Child

Other

Insurance Plan Name:

Insurance Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Insurance Company Phone Number:

Insurance Authorization:

By checking this box,
I authorize my insurance company to pay the dentist all insurance benefits rendered.
I authorize the use of this electronic signature on all insurance submissions.
I authorize the dentist to release all information necessary to secure the payment of benefits.
I understand that I am financially responsible for all charges whether or not paid by insurance.

Appointment Cancellation Policy

We value your time and make every effort to see you on time for your appointments. When you schedule an appointment with us, this time is reserved exclusively for you. Any change in this appointment affects many people, so we require notice of two business days (48hrs) if you are unable to keep your appointment. *Please Note: We reserve the right to dismiss a patient from our practice for repeated ?No Show? or same day cancellations. Signing this form indicates that you understand and will comply with our cancellation policy.

Financial Policy

Payment for your dental treatment is due at the time of service, unless financial arrangements are made prior to treatment. This policy is instrumental in helping us keep dental care costs down for our patients by reducing the significant expenses associated with billing procedures. There is a $25.00 fee for each returned check and balances over 60 days are subject to interest at the rate of 1.5% per month at our discretion. We offer 3rd party financing through Care Credit and Lending Club in addition to credit card, cash, and check payments. $150-refundable deposit is required to schedule appointments for procedures such as: crown/veneers, root canal, implant, and periodontal procedures. The deposit is non-refundable should you cancel the appointment without full 24 hour notice during our normal business hours.

Dental Insurance Policy

We are happy to submit your insurance claim, but please remember that your insurance plan does not guarantee payment will be made on your behalf. Any procedures ?not covered? by your plan will be provided to you at our fee for service rate. We make every effort to estimate your co-payments and to help you understand your benefits. The patient is ultimately responsible for any amount not paid by insurance. We reserve the right to modify this policy at any time without further notice. Signing this form indicates that you understand and will comply with our financial policy.

Authorization and Consent

I agree and consent to dental examination by this office. I understand that diagnostic procedures and dental treatments may be recommended and will be discussed in advance. To the best of my knowledge, I have completed this paperwork accurately and I will bring all future changes in my medical or dental history to the attention of the doctor. I understand that providing incorrect or incomplete information can be dangerous to my health. I grant permission for the office to contact me at home or work via telephone, email, or text messages. I will not hold my dentist, or any other member of her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

*By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the Administration Form.(Required)

*By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the Administration Form.

HIPAA Acknowledgement

This notice describe 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 protected health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect today (updated 1/2011), 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 provide the new Notice at our practice location, and we will distribute it 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.

Your Authorization: In addition to our use of your health information for the following purposes, 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.

Uses and Disclosures of Health Information: We use and disclose health information about you without authorization for the following purposes.

Treatment: We may use or disclose your health information for your treatment. For example, we may 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. For example, we may send claims to your dental health plan containing certain health information.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. For example, 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.

To You or Your Personal Representative: 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 your personal representative, 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 absence or incapacity or in 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 mmon 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.

Disaster Relief. We may use or disclose your health information to assist in disaster relief efforts.

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.

Public Health and Public Benefit: We may use or disclose your health information to report abuse, neglect, or domestic violence; to report disease, injury, and vital statistics; to report certain information to the Food and Drug Administration (FDA); to alert someone who may be at risk of contracting or spreading a disease; for health oversight activities; for certain judicial and administrative proceedings; for certain law enforcement purposes; to avert a serious threat to health or safety; and to comply with workers' compensation or similar programs.

Decedents: We may disclose health information about a decedent as authorized or required by law.

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 the protected health information of an 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).

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. You may also request access by sending us a letter to the address at the end of this Notice. We will charge you a reasonable cost-based fee for the cost of supplies and labor of copying. If you request copies, we will charge you $1.00 for each page, $9.00 per hour for staff time to copy your health information, and postage if you want the copies mailed to you. 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, health care 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. In most cases we are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in certain circumstances where disclosure is required or permitted, such as an emergency, for public health activities, or when disclosure is required by law). We must comply with a request to restrict the disclosure of protected health information to a health plan for purposes of carrying out payment or health care operations (as defined by HIPAA) if the protected health information pertains solely to a health care item or service for which we have been paid out of pocket in full.

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation of 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: You may receive a paper copy of this notice upon request, even if you have agreed to receive this notice electronically on our Web site or by electronic mail (e-mail).

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: Ray Cros, D.M.D.

Address: 71843 Highway 111, Ste A, Rancho Mirage, CA 92270

Telephone: 760-444-3202. ©2002, 2009 American Dental Association. All Rights Reserved Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association. This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002; January 30, 2009)

I have read and acknowledge receipt of the above Notice of Privacy Practices.

You may refuse to sign the acknowledgement document.

By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the HIPAA Disclosure Form.(Required)
*By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the HIPAA Disclosure Form.

Consent for Internet Communications
TI grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured web site for the dental practice. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice web site with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns. I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the web site on my behalf. I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES.
*I have read the information above regarding the secured uploading of patient information practice, and grant the dental practice permission to securely upload my patient information(Required)
*I have read the information above regarding the secured uploading of patient information practice, and grant the dental practice permission to securely upload my patient information

Name of person filling out this form:(Required)
Relationship to patient:(Required)
Self
Mother
Father
Guardian
Other
Please take a moment to let us know about your medical history so we may serve you more effectively overall heath and well-being.
Would you consider yourself to be in fairly good health?

Yes

No
Within the past year, have there been any changes in your general health?

Yes

No
What is the date (or approximate date) of your last medical exam?
Your Primary Care Physician's name, address, & phone number:
Please mark any of the following to indicate Yes in response to the question:
Have you ever had complications following dental treatment?
Are you currently under the care of a physician due to a specific condition?
Have you been hospitalized within the last 5 years due to a surgery or illness?
Are you currently taking any prescription or non-prescription medications?
Do you use tobacco (smoking or chewing)?
Do you require the use of corrective lenses (contacts or glasses)?
Do you have any other conditions, diseases, etc. not listed above that we should be aware of?

If any of the previous questions are marked, please explain:
WOMEN ONLY: Are you pregnant?

Yes

No
If Yes, when is the due date?
MM slash DD slash YYYY

Please indicate if you have experienced any of the following?
Pre-Med - Amox
Allergy - Aspirin
Allergy - Latex
Anemia
Blood Disease
Epilepsy
Head Injuries
High Blood Pressure
Liver Disease
Pacemaker
Rheumatic Fever
Stroke
Venereal Disease
Pre-Med - Clind
Allergy - Codeine
Allergy - Other
Arthritis
Cancer
Excessive Bleeding
Heart Disease
HIV
Mental Disorders
Pregnancy
Rheumatism
Tuberculosis
Pre-Med Other
Allergy - Erythro
Allergy - Penicillin
Artificial Joints
Diabetes
Fainting
Heart Murmur
Jaundice
Liver Disease
Radiation Treatment
Sinus Problems
Tumors
Allergies
Allergy - Hay Fever
Allergy - Sulfa
Asthma
Dizziness
Glaucoma
Hepatitis
Kidney Disease
Other
Respiratory Problems
Stomach Problems
Ulcers

Do you have any other health issues or allergies?
Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment
Do you take antibiotic premedication for your dental visits? If yes, please explain
List all medications, drugs, pills or herbal remedies, including regular dosages of aspirin.
*By checking this box, I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and had responded accordingly. There are no other medical conditions or medications/allergies that have not been listed. I am aware that I must notify the practice of any future changes.(Required)
*By checking this box, I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and had responded accordingly. There are no other medical conditions or medications/allergies that have not been listed. I am aware that I must notify the practice of any future changes.

Examination and Radiographs
Examination and Radiographs
I understand that I will be receiving a dental examination from a state licensed practitioner. A radiograph provides the practitioner imaging of both your hard tissues (teeth and bones) and the soft tissues that surround your teeth and jaw-bones. Without radiographs (x-rays), the dentist/practitioner is unable to diagnose: caries (tooth decay) that develops between the teeth or under restorations (fillings); diseases in the bone; periodontal (gum and bone) disease, infections that develop under your gums & some types of tumors and/or cysts.

Early detection of an infection, disease, or injury also can limit or prevent further damage to other areas of the mouth.

Safety of Dental Radiographs

The amount of radiation used to obtain dental radiographs is very small. Example: bitewing radiographs (x-rays) expose a patient to about 0.005 millisieverts (mSv) of radiation. Radiation is part of our environment; people in the United States are exposed, on average, t 3.2 mSv every year from background sources of radiation. Dentists follow the ALARA principle (?As Low As Reasonably Achievable?) when obtaining radiographs: use of fastest image receptor (we use digital), reduction of size of beam, & use of leaded aprons with thyroid collars.

Patients who have received radiation treatment for head and neck cancer can undergo dental radiography safely. In fact, head and neck radiation treatment can increase the risk of developing tooth decay, making the radiographs even more important.

Pregnancy

Please let us know as we will take minimal radiographs of your immediate area of concern until after childbirth.

I understand that without dental radiographs, my practitioner will not be able to diagnose and prescribe any dental treatment (including dental cleanings).
Print Name(Required)
Signature(Required)
Date(Required)
MM slash DD slash YYYY

Cancellation Policy for Hygiene (cleanings) and Major Dental Treatment:
Your appointment time is important to us and we are only able to see 1 patient at a time. Appointments times reserved for you are typically (45minutes-1 hour) for your individual dental care. Full mouth deep cleanings (scaling and root planing), dental crowns, root canals, bridges, and implants typically take (1-3+ hours) on average.

We ask you to please provide us with a 48 hour notice if you are unable to keep your appointment as we simply would not have enough time to fill your appointment with another patient.

We understand that emergencies do occur and of course those would be forgiven (being called-in to work is not an emergency and the cancellation fee would not be waived).

At Cros Dental, we are asking the same courtesy with appointment times reserved for you as you would your other appointments (example: facials, massage, hair stylist, & medical appointments).

Missed appointments or cancelled appointments with less than 48 hour notice are charged $45 for regular cleaning or fillings appointments and $150 for Deep Cleanings or dental treatment requiring more than 1 hour.

We value your time and loyalty to our practice and we will make every effort to accommodate your appointment preferences and provide advance notice of any changes in our schedule. Thank you for your support and loyalty to our practice and we are very grateful for your business.

I understand and accept this agreement as part of my care at Cros Dental.
Print Name / Signature(Required)
Date(Required)
MM slash DD slash YYYY

Velscope
Our practice continually strives to provide enhancements in oral health care for our patients. We are concerned about oral cancer and screen for it in every patient.

Research has shown that late detection of oral cancer is the primary reason that mortality (death) rates are so dismal. As with most othe cancers, age is the primary risk factor for oral cancer but is found in adolescence and young adults as well. Tobacco use is also a major predisposing factor, however, 1 in 4 who are diagnosed with oral cancer have no known risk factors. We find that using the Velscope improves our ability to identify suspicious areas that may be visible during the conventional oral cancer exam. Early detection of precancerous tissue can minimize or eliminate the potentially disfiguring effects of oral cancer and possibly save your life. This exam is a painless ?blue? light that the doctor uses to view all tissues visible in the oral cavity.

The VELscope® Vx system is a powerful device for the discovery of mucosal abnormalities such as:

Viral, fungal and bacterial infections

Inflammation from a variety of causes (lichen planus and lichenoid reactions, allergy to amalgam fillings, etc.)

Squamous papillomas

Salivary gland tumors

Cancer and pre-cancer

Oral HPV 16/18 infection (Human Papilloma Virus)

Unlike other adjunctive devices used by dentists, the VELscope® Vx system does not require any dyes or prolonged testing procedures. In fact, VELscope® Vx examinations can be performed in the dentist's office during routine exams (and under normal lighting conditions) in about two minutes.

The Fee is $40.00
I authorize Dr. Cros to perform the Velscope Oral Health Scan. I accept financial responsibility for this exam.(Required)

Yes

No