Dental Care In Your Home, Inc.
INSTRUCTIONS FOR FILLING OUT THE NEW PATIENT FORMS
Welcome to Dental Care In Your Home, Inc.
So that we can serve your dental needs according to your expectations, we would like to ask you a few questions.
DENTAL INSURANCE INFORMATION
DENTAL TREATMENT CONSENT FORM FOR DENTAL CARE IN YOUR HOME, INC. PATIENTS
1. DRUGS AND MEDICATIONS (prescribed and administered by a licensed dentist) I understand that antibiotics, local anesthesia, analgesics and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction).
3. REMOVAL OF TEETH I understand removing teeth does not always remove all the infection, if present, and it may be necessary to have further treatment. I understand the risks involved in having teeth removed, some of which are pain, swelling, spread of infection, dry socket, loss of feeling in my teeth, lips, tongue and surrounding tissue (Paresthesia) that can last for an indefinite period of time (days or months) or fractured jaw. Post-operative instructions will be given to you or care provider verbally and written.
5. TEETH CLEANING AND RECALL APPOINTMENTS: I understand that chronically inflamed gums put me more at risk for cardiovascular disease, type II diabetes, chronic obstructive pulmonary disease and the possibility of losing my teeth. I understand that I may need more than one cleaning every six months to gain and maintain healthy gums.
I understand that dentistry is not an exact science and that, therefore, reputable practitioners cannot guarantee results. I acknowledge that no guarantee or assurance has been made to me by anyone regarding the dental treatment that I have requested and authorized for myself or my minor child. I have had full opportunity to discuss and ask questions regarding the dental treatment, and all questions have been answered to my satisfaction.
HIPAA Privacy Authorization Form
Authorization for Use or Disclosure of Protected Health Information. (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)
AUTHORIZATION: I authorize Dental Care In Your Home, Inc. to use and disclose the protected health information described below to my insurance company or specialist or my physician.
This medical information may be used by the person I authorize to receive this information for dental treatment or consultation, billing or claims payment, or other purposes as I may direct.
This authorization shall be in force and effect until I withdraw this authorization in writing, at which time this authorization expires.
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.
I understand that my treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I sign this authorization.
I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.