Jared R. Anderson DDS | Amberena L. Fairlee DMD

499 SW Upper Terrace Drive, Suite B, Bend, OR, 97702

info@selectcaredental.com

541.323.3930

The Patient

Name:
Preferred Name:
Gender:
Birth Date:
Age:
SS#:
Home Address:
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Home Phone:
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Family Members Seen Here:
Employer:
Occupation:
Emergency Contact Name:
Emergency Contact Phone:
How did you hear about our office?

Medical History

Are you currently under a physician’s care?
If so, why:
Please list all current medications:

Women

Are you pregnant?
Nursing?
Taking Oral Contraceptives?

Do you or have you had any of the following? Please select.

Are you allergic to any of the following?

List all other allergies:
Do you use tobacco?
Do you use controlled substances?
Have you ever taken Fosamax, Boniva, Actonel or any other bisphosphonates?
Have you ever had to pre-medicate with an antibiotic before a dental appointment?
Do you have a history of chemical or alcohol dependency?
Are you on a special diet?
Have you ever been hospitalized or had a major operation?
Do you have any other health concerns or illnesses not listed above?
Preferred Pharmacy:
Location:

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Responsible Party Information (If Different from the Patient)

Name:
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Date of Birth:
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Home Phone:
Work Phone:
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Preferred Contact Method:

Primary Dental Insurance (If Applicable)

Name of Subscriber:
Subscriber Date of Birth:
Subscriber SSN #
Member ID#
Group #
Insurance Co. Name:
Insurance Co. Address:
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Employer/ Group Name:
Insurance Co. Phone #

Secondary Dental Insurance (If Applicable)

Name of Subscriber:
Subscriber Date of Birth:
Subscriber SSN #
Member ID#
Group #
Insurance Co. Name:
Insurance Co. Address:
City:
State:
Zip:
Employer/ Group Name:
Insurance Co. Phone #

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FINANCIAL OPTIONS AND AGREEMENT

Thank you for choosing us for optimal oral health care. We have found that our patients appreciate knowing exactly what to expect from us both from a philosophy aspect and a financial aspect. Therefore, we prefer to inform our patients of these before we begin any treatment.

Our Vision

Providing complete, life-long dentistry with excellence and integrity, while keeping a focus on the whole person.

Financial Arrangements

We offer the following methods of payment for services provided. This will allow us to focus on our specialty, providing you with superior customer service and optimal in a comfortable environment using up-to-date materials while keeping our fees as affordable as possible.

  1. 1. Cash, Check, Debit Card, Mastercard, Visa, Discover & American Express Accepted
  2. Payment in full is due on the day services are performed unless financial arrangements have been made prior to treatment.
  3. 2. Dental Financing Plan
  4. We have made arrangements with Care Credit, Lending Club, and Compassionate Finance that will finance your dental work with approved credit. This will allow you to complete your dental work without delay and have low monthly payments with interest-free options also available. Application forms are available at the reception desk.

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Dental Insurance

We ask that you realize that we do not work for an insurance company. Rather, we work 100% for our patients. We feel that insurance can be a great benefit for many patients and can help offset the investment of getting quality dental care performed on you and your family. We want you to know we will do everything in our power to ensure you get every benefit allotted in your insurance contract. However, the treatment we recommend and the fees we charge will always be based on your individual needs, not your insurance coverage. Please realize that “dental insurance” isn’t really insurance (a payment to cover the cost of a loss). It is actually a money benefit, typically provided by an employer, to help their employees pay for routine dental services. The employer usually buys a plan based on the amount of the benefit and how much the premium costs per month. Most benefit plans are only designed to cover a portion of the total cost of a person’s necessary dental treatment. For example, a dentist may recommend a crown for a tooth that has extensive decay, however, the dental plan may only cover the cost of a filling. This does not mean that the patient does not need a crown, only that the benefit is limited to a filling.

Most insurance companies will not cover 100% of all dental expenses. Your portion, not covered by insurance, is due at the time treatment is performed. Please understand that dental insurance is a contract between the patient and the insurance carrier, and not between the insurance carrier and the dentist. The patient is still the responsible party regarding all dental fees, regardless of dental insurance reimbursement. We will be glad to process your insurance benefit forms as a courtesy at no charge. If the insurance company has not paid their portion after 90 days of services rendered, you will need to make full payment to this office and be reimbursed when the insurance company pays.

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Dental Insurance Estimates

Based on the information we have from your dental insurance company, we will estimate your portion of dental fees and payment will be due at the time of service. If there is a balance due after your insurance company pays their portion, you will be billed for any amount unpaid. You are responsible for any charges exceeding your benefits. As a courtesy, our office will assist in making collections from the insurance company by filing the necessary forms. However, our office cannot render services based on the assumption that charges will be paid by the insurance company.

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Appointments, Timeliness, and Communication

Please remember that your appointments are reserved specifically for you. We are committed to seeing you on-time and request that you arrive on-time for your visits as well. We want to ensure all patients are seen when promised. We request that at least 48-hours notice be given if an appointment needs to be rescheduled or cancelled. We prefer open and honest communication in our office and request your permission to tell you the exact condition of your oral health and to explain the optimal way to treat it.

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Treatment Fee Estimates

Dental treatment fees given are based on the treatment anticipated at the initial comprehensive examination. Some teeth may have hidden decay or fractures, affected nerves or other unanticipated conditions requiring more extensive dental treatment. In situations where additional charges are involved, we will explain the reason for additional treatment needed. Our financial coordinator will discuss the additional fees and financial arrangements involved.

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Interest

A 1.5% monthly interest charge (18% APR) will be applied to ALL BALANCES OVER 30 DAYS PAST DUE.

Accounts that are unpaid for more than 90-days may be sent to a third-party collection agency, in which case a 40% charge on the unpaid balance will be applied to the account.

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Returned Checks

A $40.00 charge will be applied to all returned checks.

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Please feel free to contact us if you have any questions or concerns regarding dental treatment or financial arrangements.

Acknowledgement of Receipt of HIPAA Privacy Practices Notice

Patient Name:

Purpose of Consent:

By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices:

You have the right to read our HIPAA Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. We encourage you to read it carefully and completely before signing this consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information we maintain. You may obtain a copy of our Notice of Privacy Practices, at any time.

Contact Person:
Any staff member of Select Care Dental
Phone: (541) 323-3930 | Fax: (541) 323-3929
Email: info@selectcaredental.com
Address: 499 SW Upper Terrace Drive Suite B, Bend, OR 97702

Right to Revoke:

You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.

Patient's Signature:

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Date:

If this consent is signed by a personal representative on behalf of the patient, please complete the following:

Responsible Party’s Name:
Relationship to Patient:

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.