Patient Form - Dr. Chen Dentistry

Step 1 of 5

MEDICAL HISTORY
Child's Physician(Required)
Phone
Address(Required)
Date of last exam(Required)

Please describe any current medical treatment including medications, pending surgery, recent injuries, or any other information that the dentist should know:
Are there any behavioral or emotional problems you would like to bring to our attention?

YES

NO
DENTAL HISTORY
Date of last dental visit

Does your child brush daily?

YES

NO
Describe
Do you assist your child with brushing/flossing

YES

NO
By Dr.
How often?
Has your child complained about any dental problems?

YES

NO
Is dental floss used?

YES

NO
Any injuries to mouth, teeth, head?

YES

NO
Water supply _Well _ City
Describe
Child's attitude towards dentistry
History of any mouth habits:
thumb sucking, nail biting, mouth breathing, finger sucking, pacifier, etc.

YES

NO
Family history of missing/extra teeth

YES

NO
Describe habit & how long
If bottle fed, at what age was bottle removed?
If breast fed, at what age weaned?
Reason for today's visit
Do you have any current x-rays & referral forms if transferring from another practice?
(Required)
I hereby certify that the foregoing information is correct and true. Because the above named child is a minor, it is necessary that a signed permission is obtained from a parent or guardian before any and/or all necessary dental treatment can be commenced. Authorization is hereby granted as so. Furthermore, I will be responsible for any professional fees incurred for my child. I understand that I am responsible for all changes whether or not covered by insurance. All balances over 30 days are subject to a 1.5% per month service charge. Overdue balances more than 90 Days that have been turned to collections will be assessed a collection fee.
Signature(Required)
Date

Relationship to patient

Stephanie C. Chen, DDS, MS, PA

2813 Coltsgate Road Suite 100
Charlotte NC 28211
704-365-0888

Financial Policy

PAYMENT POLICY:

Please be aware that the parent/guardian bringing the child to the appointment is legally responsible for the payment of all charges. This parent/guardian will be responsible for all the fees regardless of any custody agreements or court orders. This office will not be involved in any custody disputes, financial or otherwise. All appointments either cancelled or broken within 24 hours will incur a $60.00 fee.

We operate on a fee for service basis; therefore a payment will be necessary at every visit.

Payment options if you are self pay:

A.You may choose to pay by cash, check, or MasterCard/Visa.

B.On treatment involving laboratory fees(bridges,orthodontic appliances) you may choose to pay 50% on the preparation date and the balance on the delivery date.

C.All dental treatment is expected to be paid in full at the time of service.

Payment options if you have insurance:

A.Dr. Chen is not a participating provider with insurance, therefore, co-pays and reasonable and customary charge acceptance does not pertain in any way to this office.

B.We can file some insurance claims, as a courtesy; however, the patient is responsible for the balance on account if insurance has not paid within 60 days. We will help in any way to speed the processing of all claims. As Dr.Chen is not contracted with any insurance company, it is the parents responsibility to follow up with the insurance carrier and maintain current/updated information with our office.

C.If your insurance carrier is a reimbursment, you may pay according to self pay options.

D.If you have new insurance and do not have the information for our office to file your claim, payment will be expected in full for services and you will be provided with a standard dental claim to file for reimbursment.

Insurance is a contract between you and your insurance company. Please be aware of the benefits of your policy. Although we may estimate what your insurance company may pay, it is the insurance carrier that makes the final determination of payable benefits.

If you have any questions concerning these policies, please do not hesitate to ask our administrative staff.

Once you have signed this agreement, you agree to all of the terms and conditions contained herein.

Date

(Required)
Patients Name
Name
Responsible Party's Name (printed)
Responsible Party's signature(Required)

STEPHANIE CHEN, DDS, MS, PA

Acknowledgement of Receipt
Of Notice of Privacy Practices

Patient Name & Address:(Required)
(Required)
I have received a copy of the Notice of Privacy Practices for the above named practice.
Signature(Required)
Date(Required)

For Office Use Only
We were unable to obtain a written acknowledgement of receipt of the Notice of Privacy Practices because:
An emergency existed & a signature was not possible at the time.
The individual refused to sign.
A copy was mailed with a request for a signature by return mail.
Unable to communicate with the patient for the following reason:
Other:
Prepared By(Required)
Signature(Required)
Date

Notice of Privacy Act available upon Request

Authorization to Release Health Information – Compound Release

Name of Patient:
Date of Birth:

Stephanie C. Chen, DDS, MS, PA is authorized to release PHI about the above named patient in the following manner and/or to selected persons.
CHECK EACH PERSON/ENTITY APPROVED TО RECEIVE INFORMATION.
CHECK TYPE OF INFORMATION THAT CAN BE GIVEN TO PERSON/ENTITY ON THЕ LEFT IN THE SAME SECTION.
Voice Mail
Results of lab tests/x-rays
Other:
Other(s): (provide name and phone number)
Financial
Medical
(Required)
Email communication-Provide email address*
Financial
Medical
Appointment reminders
Breach notification
*For email communication to occur, please accept the disclosure below.
(Required)
Text communication - Provide number *
Appointment reminder
Other:
*For text communication to occur, accept the disclosure below.
(Required)
* Acknowledge for email and/or text communication I understand that if information is not sent in an encrypted (secure) manner, there is a risk it could be accessed inappropriately. I still elect to receive email and/or text communication as selected.
Photo of patient received by patient or legal guardian
Photo taken by staff (Example: pre/post procedure)
Other:
May be posted at the office
May be posted on website
Other:
Patient's Rights:

I have the right to revoke this authorization at any time in person or in writing.

I may inspect or copy the protected health information to be disclosed as described in this document.

Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.

Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.

I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.

I understand released information may include a communicable disease diagnosis such as HIV or a diagnosis related to mental health or substance abuse.

This authorization will remain in effect until revoked by the patient in writing.
Signature of Patient or Personal Representative:(Required)
Date:

*Description of Personal Representative's Authority (attach necessary documentation)
REVOKED
How:
in person on
Date

(date) If in person, signature is required.
Signature of Patient or Personal Representative:(Required)
in writing (place copy in patient's file)

Patient Forms

WELCOME TO STEPHANIE C. CHEN, DDS, PEDIATRIC DENTISTRY

LET’S GET ACQUAINTED

MEDICAL HISTORY

MEDICAL HISTORY

DENTAL HISTORY

Stephanie C. Chen, DDS, MS, PA

Financial Policy

STEPHANIE CHEN, DDS, MS, PA

Acknowledgement of Receipt
Of Notice of Privacy Practices

For Office Use Only

Authorization to Release Health Information – Compound Release

CHECK EACH PERSON/ENTITY APPROVED TО RECEIVE INFORMATION.

CHECK TYPE OF INFORMATION THAT CAN BE GIVEN TO PERSON/ENTITY ON THЕ LEFT IN THE SAME SECTION.

Patient's Rights:

REVOKED

Office Hours

Resources

Contact Us

Patient Forms

WELCOME TO STEPHANIE C. CHEN, DDS, PEDIATRIC DENTISTRY

LET’S GET ACQUAINTED

MEDICAL HISTORY

MEDICAL HISTORY

DENTAL HISTORY

Stephanie C. Chen, DDS, MS, PA

Financial Policy

STEPHANIE CHEN, DDS, MS, PA

Acknowledgement of ReceiptOf Notice of Privacy Practices

For Office Use Only

Authorization to Release Health Information – Compound Release

CHECK EACH PERSON/ENTITY APPROVED TО RECEIVE INFORMATION.

CHECK TYPE OF INFORMATION THAT CAN BE GIVEN TO PERSON/ENTITY ON THЕ LEFT IN THE SAME SECTION.

Patient's Rights:

REVOKED

Office Hours

Resources

Contact Us

Acknowledgement of Receipt
Of Notice of Privacy Practices