Steve Flores D.D.S., M.S

4613 Bee Caves Road, Suite 203

512-872-4883

Patient Information

Date:
Patient Name:
Preferred Name:
Home Address:
Apt.#:
City:
State:
Zip:
Home Phone:
Cell Phone:
Social Security No:
Date of Birth:
Driver's License:
Employer:
Business Phone:
Exp:
Occupation:
Would you like to be contacted via e-mail?
E-mail Address:

Responsible Party (if someone other than the patient)

PERSON RESPONSIBLE FOR PAYMENT OF ACCOUNT:
Relationship:
Home Phone:
Bus.Phone:
PERSON RESPONSIBLE FOR PAYMENT OF ACCOUNT:
Social Security No:
Home Phone:
Bus Phone:
ARE YOU COVERED BY A DENTAL INSURANCE PLAN?

Dental Insurance

We will be unable to file your insurance unless this is properly and fully completed. Please complete only if this is dental insurance.

Name of Insured:
Relationship:
Social Security No. of Policy Holder:
Date of Birth:
Insurance Co. Name:
Policy & Group No:
Insurance Co. Address:
City:
State:
Zip:
Phone:
Employer of Policy Holder:
Employer Address:

YOUR SIGNATURE IS REQUIRED IN ORDER FOR US TO:

  • Process all Insurance claims
  • Extend credit to you for services rendered (when applicable)
  • Ensure payment for services rendered
  • Release medical information to Insurance companies
  • Release information to other medical/dental providers, when necessary
  • Acknowledge that you have read/signed this office's Privacy Practices as required by HIPAA and understand that a
  • copy is available to you at all times.

I authorize the release of all medical/dental information necessary to process my claims. I authorize the release of this same information, when necessary, to other providers rendering medical/dental care. I assign all dental benefits to which I am entitled, to Periodontal Health Professionals for their services. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.

I understand that my dental insurance carrier may pay less than the actual amount charged for services. I understand that I am fully responsible for any and all payments due on my account. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payment of services not paid, in whole or in part, by my insurance provider.

**A $50 fee will be charged for rescheduled or cancelled appointments with less than 48 hours notice. For procedures, 25% of the total may be charged if cancelled with less than 72 hours notice.**

Patient Signature:

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Name:

Responsible Party Signature:

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Name:

Medical History

PATIENT NAME:
Date:

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, Explain
Medical Doctor's Name:
Phone:

Have you ever been hospitalized or had a major operation?
If yes, Explain
Have you ever had a serious head or neck injury?
If yes, Explain
Have you ever taken Fosamax, Boniva, Actonel or any other medication that contains bisphosphonates?
If yes, Explain
Do you drink more than 2 alcoholic beverages per day?
If yes, Explain
Do you use tobacco?
If yes, how much?
Do you use controlled substances?
If yes, explain
Do you now or have you in the past used illicit drugs?
If yes, explain

For Women Only

Women:  

Are you allergic to any of the following?


Do you have, or have you had, any of the following? (please check only those that apply)

Have you ever had any serious illness not listed above?
If yes, explain
Are you currently taking any medications, vitamins, and/or herbs? (please list)
If yes, explain
Do you take aspirin or any blood thinner, daily?
If yes, explain
Why are you seeking periodontal treatment?

Have you ever been treated for periodontal disease (gum disease, pyorrhea, trench mouth)?
Do you use the following?

Do you have or have you ever had any of the following?

Bleeding/Sore gums
Loose teeth
Unpleasant taste/bad breath
Sensitive to hot
Burning tongue/lips
Sensitive to cold
Frequent blisters, lips/mouth
Sensitive to sweet
Swelling/lumps in mouth
Sensitive to biting
Ortho treatment (braces)
Food impaction
Biting cheeks/lips
Clenching/grinding
Clicking/popping jaw
Shifting of teeth
Pain in jaw joint (open/close)
Change in bite

Oral Hygiene:

Do you use the following?
How often do you brush?

Brush is:
Your Dentist
How long?
Date of last dental visit?
Date of last cleaning?
Comments:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing the incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

SIGNATURE OF PATIENT/PARENT/LEGAL GUARDIAN:

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Date:

Financial Policy

Welcome to our office. Our goal is to provide you with the highest quality dental care in a professional atmosphere. It is our policy to make financial arrangements with you before any treatment begins. Below is an explanation of our payment procedures:

I have read and accept the above Financial Policy. I understand it and agree to the terms set forth regarding payment.

Signature of Patient/Responsible Party:

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Date:

PHP Representative Signature:

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Date:

Understanding your insurance when seeing an out-of-network provider:

Each Insurance company goes by what's called a fee schedule, which means they allow a certain amount for each procedure. Because we are not under contract with any insurance companies, we are not privy to Individual company's fee schedules. As an out-of-network provider, we have our own fee schedule which Is based on reasonable and standard area prices.

For example, we may charge $415 for procedure X, but your insurance's fee schedule may only allow $375 for procedure X. When your insurance company says they will pay 80% of procedure X, what they mean Is they will pay 80% of their "allowed fee", not 80% of what we charge.

Although the insurance database may indicate that the treatment will be covered, Issues such as deductibles, frequency limitations and a required prior history of periodontal surgeries/treatments may make your claim ineligible for payment.

We are happy to give you an estimate for your procedure but be aware that due to the difference in our fee and your insurance company's "allowed fee" you may still have a balance after your insurance claim(s) has been paid.

If you would prefer, you can pay for your services in full and we will flle the claim to the Insurance company and have them remit the payment to you.

Signature of Patient

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Date:

PHP Representative Signature:

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Date:

REQUEST FOR CONFIDENTIAL COMMUNICATIONS

The HIPAA Privacy Rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI)

I certify that I understand the privacy risks of mail, telephone and email. I hereby authorize a representative or my physician to mail, call or email me with communications regarding my healthcare, including but not limited to such things as appointment reminders, laboratory results and referral arrangements. I understand that I have the right to rescind this authorization at any time by notifying us in writing.

Name of Patient:
Effective Date:
DOB:

If we need to reach you during business hours regarding any information pertaining to upcoming appointments and/or treatment recommendations, how may we reach you? (check all that apply)












I give permission to send any information via secure encrypted email:
Email Address:

I give permission to disclose and discuss any information related to my medical condition(s) to/with the following:

Relationship
Relationship
Relationship

Signature of Patient

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Date:

AUTHORIZATION FOR RELEASE OF IDENTIFYING HEALTH INFORMATION

Patient Name:
Patient Account Number:
Patient Phone Number:
Patient Address:

I authorize the professional office of my dentist named above to release health information identifying me (including, if applicable, information about HIV infection or AIDS, information about substance abuse treatment and information about mental health treatment) under the following terms and conditions:

1. Detailed description of the information to be released:

2. To whom the information may be released (I.E. patient's dentist, medical doctor, caregiver):

3. The purpose(s) for the release (if the authorization is initiated by the individual, it is permissible to state "at the request of the individual" as the purpose, if desired by the individual):

4.Expiration date or event relating to the individual or purpose for the release:

It is completely your decision whether or not to sign this form. We will not refuse to treat you if you choose not to sign, however, without your signature we cannot share any information with your dentist(s) and/or medical doctors
(I.E. x-rays, recommended treatment, notes about your exam and/or surgery, notes about your hygiene visits)

If you sign this authorization, you can revoke it later. The only exception to your right to revoke is if we have already acted In reliance upon this authorization. If you want to revoke this authorization, send us a written or electronic note telling us that your authorization is revoked. Send this note to the office address listed at the top of this form.

When your health information is disclosed as provided in the authorization, the recipient has no legal duty to protect its confidentiality. In some cases, the recipient may re-disclose the information as he/she wishes. Individual state or federal laws may change this possibility.

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. I AUTHORIZE THE DISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBED IN THIS FORM.

Patient Signature:

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Date:

If you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form:

Source of Authority Signature:

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Relationship to Patient:
Print Name: