Patient Forms

Patient Information

Contact Information:

Please fill out all information to the best of your knowledge. All patient information will be kept confidential. If you have any questions, we will be happy to assist you.

Date:*

First Name:*

Last Name:*

I prefer to be called:

Gender:*

Male

Femeale

Date of Birth:*

Social Security #:

Mobile Phone:*

Home Phone/Other:

Email*

Patient Address:*

City:*

State:*

Zip:*

Marital Status:*

Other family members treated by us:

How did you hear about our office?*

Emergency Contact:

This should be the nearest relative who does not live with the patient, or a parent/guardian if the patient is a minor.

First Name:*

Last Name:*

Relationship to Patient:*

Mobile Phone:*

Home Phone/Other:

Email Address:

Person Responsible for Account:

**If the patient is responsible for their own account, please skip this section.

First Name:

Middle Name:

Last Name:

Relationship to Patient:

Date of Birth:

Social Security#:

Mobile Phone:

Home Phone/Other:

Email Address:

Occupation and Employer:

Billing Address:

City:

State:

Zip:

Insurance Information

If patient is uninsured, please sign the PHI Authorization before skipping to the next section.

Note: Insurance company information is usually included on the back of the member’s insurance card. If insurance company is Delta Dental of Michigan or Priority Health, you might not have received a card, in which case you may indicate “DDMI” in the phone and address boxes instead.

Primary Insurance:

Insurance Holders Name:*

Date of Birth:*

Relationship to Patient:*

Employer:*

Member ID:*

Group ID:*

Name of Insurance Company:*

Insurance Company Phone #:*

Insured’s SSN#:*

Insurance Company Address:*

Insurance Company City, State, ZIP Code:*

Does the patient have secondary insurance? If patient is uninsured or has primary insurance only, please sign the Authorization below before skipping to the next section.

Secondary Insurance: (If applies)

Insurance Holders Name:

Date of Birth:

Relationship to Patient:

Employer:

Member ID:

Group ID:

Name of Insurance Company:

Insurance Company Phone #:

Insured’s SSN#:

Insurance Company Address:

Insurance Company City, State, ZIP Code:

PHI Authorization:

All the above information is correct to the best of my knowledge. I authorize the use of this form on all my insurance submissions, and I authorize the release of information to all my insurance companies. I understand that I am responsible for my bill. I authorize Joseph Szymczak, DDS, PC dental practice to act as my agent in helping me to obtain payment from insurance companies. I authorize payment to Joseph Szymczak, DDS, PC dental practice. I permit a copy of this authorization to be used in place of the original. I give Joseph Szymczak, DDS, PC dental practice, its employees, and/or other agents express prior consent to contact me for the purpose of treatment, insurance, or payment.*

I have read, understand and agree to the terms and conditions of this PHI Authorization

Patients Full Name:

Digital Signature:

Todays Date:*

Financial Policy & Acknowledgement

The following information is to inform you of our financial policy. If, at any time, you have questions regarding this policy, please do not hesitate to ask any member of our staff.

We are committed to providing you with the highest quality level of care. Our fees reflect the quality of care we provide. We continue our commitment by offering a variety of financial options to enable you to receive the dental care you need. We accept cash, check, VISA, MasterCard, Discover, and American Express. We have also partnered with a third-party company to offer the flexibility of extended payment options.

We will communicate all recommended treatment options and associated fees prior to the start of treatment, if requested by the patient. Payment is expected at the time of treatment. A delinquent account impedes our ability to provide you with the quality dental care that you deserve. It is our policy that the parent or guardian who accompanies a child to our office for treatment is responsible for payment of all services rendered.

We are committed to respecting your time and ask that you make every effort to keep the appointment time reserved exclusively for you. We understand there may be times when you are unable to keep your scheduled appointment, however, any appointment missed may be subject to a missed appointment fee of $50. Should you find it necessary to reschedule an appointment, please provide us with notice of two business days (48 hours) to avoid being charged a missed appointment fee.

As a courtesy to our patients with dental insurance benefits, we will submit your claim and provide any necessary information to assist you in receiving your dental benefits. We require that any applicable deductibles and estimated patient portion be paid at the time treatment is rendered. It is ultimately the patient’s responsibility to work with and understand their insurance policy’s benefits and terms. It is also the patient’s responsibility to report any insurance changes to us. We do accept assignment of insurance benefits as a form of payment to help reduce your immediate out-of-pocket expense. We are a participating provider with Delta Dental only; all others are considered “out of network”. We do not participate with any adult or child Medicaid plans.

Please contact your insurance carrier prior to your visit to obtain essential information which will accurately reflect your coverage. Providing us with this information will expedite the processing of claims. If you have a direct reimbursement policy, payment in full is expected on the day of service and your dental plan will reimburse you.

Dental coverage is a contract between the patient and the insurance company. It is a benefit to assist you with the cost of dental care. At no time should insurance benefits compromise your doctor’s diagnosis or affect your choice of treatment.
It is your responsibility to understand the type of dental insurance you have (i.e. Traditional, Medicare, Medicaid) and the benefits selected by you and/or your employer.
You (not the insurance company) are responsible for the fees of services rendered.

I have read, understand and agree to the terms and conditions of this Financial Agreement.*

I have read, understand and agree to the terms and conditions of this Financial Agreement.

Patients Full Name*

Digital Signature*

Todays Date:*

HIPAA Patient Consent Form

Please indicate below the names and contact information of anyone who might need access to your protected health information (ex. parents, spouses, medical advocates).

Name:

Relationship to Patient:

Phone #:

Name:

Relationship to Patient:

Phone #:

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (a.k.a. HIPAA or The Healthcare Privacy Act). I understand that by signing this consent, I authorize Joseph Szymczak, DDS, PC dental practice to use and/or disclose my protected health information with the above-named individuals and to carry out the following:  Treatment which includes direct and/or indirect treatment by other healthcare providers.  Obtaining payment from third party payers, i.e. my dental and/or medical insurance companies.  The day-to-day healthcare operations of the dental practice. I have also been informed of and given the right to review and secure a copy of the practice's Notice of Privacy Practices (see the "New Patient Forms" section of the practice's website or ask for a copy at the front desk), which contains a more complete description of the uses and disclosures of my protected personal health information and my rights under HIPAA. I understand that the practice reserves the right to change the terms of this notice, and that I may at any time request the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and healthcare operations, but that the practice is not required to agree to use these requested restrictions. I understand that I may revoke this consent in writing at any time. However, any use or disclosure that occurred prior to the date I revoke this consent will not be affected.*

I have read, understand and agree to the terms and conditions of this HIPAA Patient Consent Form.

Patients Full Name*

Digital Signature*

Todays Date:*

Consent for Treatment

I hereby authorize the doctor or designated staff to take X-rays, study models, photographs; and other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the dental needs of the above-named patient. Upon such a diagnosis, I authorize the doctor or designated staff to perform all recommended treatment mutually agreed upon by us and to employ such assistance as required to provide proper care. I agree to the use of anesthetics, sedatives, and other medications as necessary, unless otherwise indicated in my Medical History. I fully understand that using anesthetic agents embodies certain risks. I understand my right to ask for a complete recital of any possible complications.

Patients Full Name:*

Digital Signature:*

Todays Date:*

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Email

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Patient Forms

Patient Information

Contact Information:

Emergency Contact:

Person Responsible for Account:

Insurance Information

Primary Insurance:

Secondary Insurance: (If applies)

PHI Authorization:

Dental History

Dental Concerns:

Medical History

Medical History/Medications:

Please Select “Yes” or “No” to indicate if you have had any of the following diseases, medical conditions, or procedures.

Allergies

For Women:

Authorization:

Financial Policy & Acknowledgement

HIPAA Patient Consent Form

Consent for Treatment

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