Patient Authorization, Agreements, And Acknolwedgements

Here’s to a Healthy Start! Please review how we handle the business aspect of our practice. Our #1 goal is to help you live a longer, healthier life, so you can be around longer with those you love. All this information helps us get on the same page now, so we can help you do that!

Making Appointments: I agree that any appointment I make with Dr. Hepler’s office is confirmed upon scheduling. I may receive courtesy reminders where I may click a “confirm” button, but if I make an appointment, they are expecting me to show up. Please check any that apply. How would you like your courtesy appointment reminders? Call Email Text

Cancellation Fees: In order to better serve you, we do not double book our patients. We require 48-hour notice if you are unable to make your appointment to avoid a cancellation fee of $50 for hygiene appointments and $50 per 30 min for Doctor appointments. As small business owners, this still causes us financial hardship as these fees don’t make up for the cost of broken appointments, but we hope they are a deterrent. We value and respect your time and expect the same of you. Broken appointment time drives up the cost of dentistry for everyone, so please help us keep it affordable by keeping reserved appointments.

HIPPA Privacy Notice: This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your right to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information:
Your protected health information may be used and disclosed by your dentist, our staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the dentist’s practice, and other use required by law.

Treatment:
We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information to physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment:
Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for coverage of needed treatment may require that your relevant protected health information be disclosed to your insurance company.

Healthcare Operations:
We may use or disclose, as needed, your protected health information in order to support the business activities of your dentist’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of staff, and conducting or arranging for other business activities. For example, we may use a sign-in sheet at the front desk where you will be asked to sign your name. We may also call you by name in the waiting room at your appointed time. We may use or disclose your protected health information to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required by Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, and Organ Donation, Research Criminal Activity, Military Activity and National Security, Workers’ Compensation, Inmates, and Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other Permitted and Required Uses and Disclosures will be made only with your Consent, Authorization, or Opportunity to Object unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights

You have the right to inspect and copy your protected health information.Under federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations. You may also request that any part of you protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restrictions requested and to whom you want the restrictions to apply.

Your physician is not required to agree to a restriction that you may request. If the physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another healthcare professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept his notice alternatively, ie: electronically.

You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint.We will not retaliate against you for filing a complaint.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number.

Signature below is acknowledgement that you have received and read this Notice of Privacy Practices.

Consent for Treatment: I hereby authorize Dr. Hepler or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of my dental needs. Upon such diagnosis, I authorize Dr. Hepler to perform all prescribed treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I agree to the use of anesthetics, sedatives, and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications. I give consent to Dr. Hepler or designated staff’s use and disclosure of any oral, written, or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment, and health care operations. I understand that only the minimum amount of information necessary to provide quality care will be used or disclosed, and that a notice fully outlining the protection of my personal health information is available.

Insurance Information: As a courtesy to our patients, our office will assist you in obtaining maximum benefits from your insurance. However, there are many misconceptions about dental insurance. Dental insurance pays based on the premium paid by you or your employer. Higher premium plans pay more of the fees for your dental care and have fewer exclusions. Dental insurance helps defray the costs of dental care, but it is not intended to cover it completely. Insurance requires patients to pay the portion of the fee that insurance does not cover. This is your Estimated Patient Portion.

Dental insurance policies restrict payment for some services, use restricted fee schedules, and exclude some procedures based on prior conditions or length of time on the plan. Restrictions can be based on the premium paid for insurance. While our business team will do our very best to research your insurance, in the end, this is a contract between you, your insurance carrier, and your employer. We love helping our patients with insurance as a courtesy, but you are ultimately responsible for understanding your plan, it’s conditions, limitations, restrictions, and exclusions. Additionally, you are financially responsible for any balance your insurance does not cover.

	-	Secondary Insurance: We are happy to file your primary and secondary dental insurance on your behalf as a courtesy and service to you. We require you pay anything that your primary insurance does not cover. As a courtesy to you, we will submit the necessary forms to your secondary insurance carrier, and the secondary insurance carrier will reimburse you directly.
	-	Medical Insurance: We are excited about the opportunities to serve our patients by learning about the latest in dental-medical cross-coding because, the current science shows us the importance of oral health to the systemic wellness of the whole body! We are diligently learning about how to file dental needs under the appropriate medical codes to get coverage and benefits for our wonderful patients. We do require that you pay for all your services based on the Estimated Patient Portion that your primary dental insurance carrier will provide. We will submit the appropriate medical claims as allowed, and allow your medical insurance to reimburse you directly.

Billing & Agreement to Pay: We estimate your portion on the date of service based on the insurance information we have at the time. It is the patient’s responsibility to keep our office updated with the most current insurance information. Our estimates are never a guarantee of how the insurance company will pay. Should the insurance company delay or deny payment for any reason, the balance will be your responsibility within 45 days.

I understand that all responsibility for payment for dental services provided in this office for myself or my dependents is mine. The undersigned accepts the fee charges as a lawful debt and promises to pay said fee including the costs of collection, attorney fees, and court costs if necessary. I agree to pay my deductible and any portion of the dental fee not covered by my dental insurance plan at the time of service. In the event payment is not received by agreed upon dates, I understand that a 1.5 % late charge (18%APR) may be added to my account. If required, I also understand a check of my credit history may be made.

Privacy Practices Acknowledgement: I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

Confidentiality and Use and Disclosure of Information: You understand that information obtained in this form will be treated as privileged and confidential and will not be released or revealed to any third party (other than for treatment, payment, or health care operations purposes) without your authorization, as described below. Dr. Hepler is committed to continuing education. Your photos, dental models, and pertinent dental and medical histories may be shared with other health professionals and patients for the purpose of education, marketing, review, and learning. Your personal information will be protected. Your signature below indicates your authorization for the dentist and the dentist’s staff to use your photos and dental records. This would authorize the publication and computer illustration of your photos for educational and marketing purposes, and you will waive all claims against any party based on the usage of the images, including, but not limited to, claims that the use of the images defames you or constitutes an infringement of your rights to privacy, or any other right you may enjoy.

Signature on File: I authorize release of information to all insurance companies and permit this copy of my signature to be kept on file for processing dental insurance claims for me and my dependents. I also understand this dental office has no contract or connection with my dental insurance company. I authorize payment to go directly to my dentist. I will notify this office if I have a change in my dental coverage.


*	I have read, understand, and agree to these authorizations, agreements, and acknowledgements.

Patient's Name:

Signature:

Doctor's Name:

Signature:

				City
State		Zip		APT#

*Home phone #:	()- -	Cell #:	()- -
Work phone #:	()- - -

What is the best way to reach you?	Home Phone	Cell Phone	Work Phone
	Email	Text

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State		Zip		APT#

Not referred - What made you call?	Drive-By	Google Search	Facebook
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Patient Information

Insurance Information

Dental history

Medical History

Patient Authorization, Agreements, And Acknolwedgements

Hot or Cold?	Yes No
Sweets?	Yes No
Biting or Chewing?	Yes No
Have you noticed any mouth odors or bad tastes	Yes No
Do you frequently get cold sores, blisters or any other oral lesions?	Yes No

Do your gums bleed or hurt?	Yes No
Did your parents experienced gum disease or tooth loss?	Yes No
Have you noticed any loose teeth or change in you bite?	Yes No
Does food tend to become caught in between your teeth?	Yes No
If yes, Where:

Clench or grind your teeth while awake or asleep?	Yes No
Bite your lips or cheeks regularly?	Yes No
Hold foreign objects with your teeth?(penciles, pipe, pins, nails, fingernails)	Yes No
Mouth breathe while awake or asleep?	Yes No
Have tired jaws, especially in the morning?	Yes No
Snore or have any other sleeping disorders?	Yes No
Do you have sleep apnea or a c-pap machine?	Yes No
Smoke/chew tobacco or use other tobacco products?	Yes No

Orthodontic treatment?	Yes No
Oral Surgery?	Yes No
Periodontal treatment?	Yes No
A bite plate or mouth guard?	Yes No
Your teeth ground or the bite adjusted?	Yes No
A seriouse injury to the mouth or head?	Yes No
If so, Please Describe, Including Cause:

Clicking or popping of the Jaw Pain? (Joint, Ear, Side of face)	Yes No
Difficulty in opening or closing the mouth?	Yes No
Difficulty in chewing on either side of the mouth?	Yes No
Headaches, neckaches or shoulder aches?	Yes No
Sore muscles (Neck, Shoulders)?	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 having dental treatment?	Yes No
If so, What is your biggest concern?
Have you ever had an upsetting dental experience?	Yes No

2.	Have you taken any medication or drugs during the past two years?	Yes No
3.	Are you taking any medication or drugs currently, including regular doses of aspirin or over-the-counter herbal medicines?	Yes No
	If yes, Please list name and dosage :

4.	Have you ever taken any prescription drugs for weight loss, including?
	Fen-Phen (fenfluramine-phentermine) Pondimen (fenfluramine) Redux (dexfenfluramine)
	If yes to the above, did you have a medical exam for heart issues?

5.	Are you aware of having an allergic (or adverse) reaction to any medication or substance?	Yes No
	If yes, Please list :

8.	Do you use more than two pillows to sleep?	Yes No
9.	Have you lost or gained more than 10 pounds in the past year?	Yes No
10.	Do you have or have you had any disease, condition, or problem not listed?	Yes No
	If yes, Please list :
11.	Women : Are you pregnant or think you may be pregnant?	Yes No
12.	Women : Nursing?	Yes No
13.	Women : Do you use birth control medications?	Yes No


*	I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the dentist of any changes in my health or medication.