logo
PATIENT INFORMATION

PLEASE TAKE NOTE: YOU MUST FILL OUT EACH FIELD BEFORE YOU SUBMIT! IF ANYTHING IS LEFT BLANK THE FORM WILL BE REJECTED!
 
Personal Information (All fields are required)
Marital Status:
Insurance Information (All fields are required)
Please note: we are looking for the information of the person who actually carries the insurance (i.e. parent, spouse, etc) ...
Dental Insurance
Is this person currently a patient in our office?
Insurance policy information
I hereby authorized treatment for my dental care. I understand that I am financially responsible to this office for professional fees & services. I also understand that the contract between my insurance company and myself is based on "usual and customary" charges and that I am responsible for all deductibles and co-payments at the time of my visit. I also understand that there will be times that my insurance does not cover all amounts and I am responsible for said amounts. If it is ever necessary for this office to employ collection counsel, I understand that I am responsible for these changes. By typing your name below you agree to the terms above and this constitutes as your digital signature.

You must provide a copy of your dental insurance card in order for us to submit claims on your behalf. We cannot submit to insurance without it.


   
Billing Policy (All fields are required)

In order to meet the needs and requests of our patients, we are enrolled in numerous insurance programs and we happily submit claims to your insurance on your behalf, if you have provided us a copy of your dental coverage card (we cannot submit to insurance without a copy of your card). We are very pleased to be able to provide this service to you, but it is extremely difficult for us to keep track of all the individual requirements of each and every plan. Each plan has a different stipulations regrading benefits. Even within the same insurance company, the plans differ depending upon what type of contract your employer has negotiated.

Providing quality dental care for our patients is our primary concern. We are more than willing to provide care within your insurance contract guidelines if you let us know at EACH visit at the time of service exactly what those guidelines are. Unfortunately, if you do not know or do not inform us of any special requirements in your insurance contract and we render services that are not covered, we will have no choice but to bill you directly for those charges. Payment for those services are your responsibility.

We understand that sometimes the patient does not know what is covered and what is not. However, often we do not and cannot know either. Also, please be aware we have no control regarding the timelines your insurance processes claims. Your estimated percentage is due on the day services are rendered and, for your convenience, our office does accept all major credit cards, the Care Credit healthcare credit card as well as personal checks and cash. Should you elect to have us submit a claim for treatment to your insurance on your behalf, we will allow 60 days from the date of service for receipt of payment from your insurance company. If there should be a delay in the insurance processing, the entire balance is due at that time. Please remember that you are ultimately responsible for payment on all services rendered in the office, regardless of your insurance coverage.

With your cooperation and help,you should be able to receive all the benefits offered to you and we will be able to concentrate on caring for your dental needs.

I have read and understand the office policy as stated above and agree to accept responsibility as described. By typing your name below you agree to the terms above and this constitutes as your digital signature.

Medical Health History
(All fields are required. Please answer yes or no for all the conditions)
Gender:
If female please answer the following:
Are you taking Birth Control Pills?
Are you pregnant?
Are you nursing?
Do you smoke or use Tobacco?
Please check any conditions you have:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Allergies:
 
 
 
 
 
 
 
 
 
 
 
Please list current medications you take:
 
Is there any disease, condition, or problem that you think this office should know about that is not covered above?
Please indicate/describe in detail anything else about your health history that you think would be useful or important for your practitioner to know:
By typing your name below you agree to the terms above and this constitutes as your digital signature.
  1. I do authorize and give consent to the doctor and his/her staff to administer treatment, including but not limited to: local anesthesia, analgesia, and other such treatment which, in their judgement, may be necessary for the prudent exercise of medical or dental care. I understand that the use of medications, anesthetics and some procedures embody certain risk.
  2. I acknowledge that no guarantee or assurance has been given by anyone as to the results that may be obtained.
  3. I consent to the disposal of any tissues or body parts that may be removed.
  4. I attached medical and dental history was completed fully and accurately, to the best of my knowledge.
  5. I understand and agree that a routine credit check from Equifax will be processed at the discretion of Foulk-Manela Pc.
  6. I understand that responsibility for payment for dental services provided int his office for myself or my dependent is mine. Unless other arrangements are made prior to treatment, accounts are to be paid on the day services are provided.
  7. I hereby authorize and direct my insurance company to pay a benefit due to me directly to this office. In the event of legal action on this account, I agree to pay any all costs of such suit, collection and attorney fees.
  8. A service charge of 1.5% per month(18% per annum) will be added to the unpaid balance of all accounts not paid in full within 90 days of the treatment date.
  9. I grant my permission to you or assigns to telephone me at home or at my work to discuss matters related to this consent, my treatment, or my account.
  10. We will happily submit your treatment to your insurance of choice for payment as a courtesy. However, payment for services rendered in the office is ultimately your responsibility.
By typing your name below you agree to the terms above and this constitutes as your digital signature.

Consent For Use And Disclosure Of Health Information (All fields are required)

Section A: Patient Giving Consent

Section B: To The Patient - Please Read The Following Statements Carefully

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 notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and 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. A copy of our Notice accompanies this Consent. 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 that we maintain.

You May Obtain a copy of Our Notice of Privacy Practices, Including any revisions To Our Notice, At Any Time By Contacting:

Contact Person: Bryan Foulk or Michael Manela
Address: 7229 N. Thornydale Road, Suite 149; Tucson, Az 85741
Telephone: (520) 744-3480
Fax: (520) 744-3473
Email: Foulk-Manela@hotmail.com

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.

Please print


have had a 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.

 

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

Notice of Privacy Practices (All fields are required)

This notice takes effect September 2013 and will remain in effect until we replace it. It describes how health information about you may be used and disclosed by our practice and how you can obtain access to this information. Please review it carefully.

We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. Our privacy practices are developed to meet requirements as specified by law. If the law changes we will amend our privacy practices to reflect the changes in the law. We must follow the privacy practices that are described in this Notice while it is in effect. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable laws, and to make new Notice provisions effective for all protected health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, inform you of changes in the Notice by getting a new signed copy from you, and we will provide copies of the new Notice upon request. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

HOW WE MAY USE AND DISCLOSE HEAL TH INFORMATION ABOUT YOU
We may use and disclose your health information for different purposes, including treatment, payment, and health care operations. For each of these categories, we have provided a description and an example. Some information, such as HIV-related information, genetic information, alcohol and/or substance abuse records, and mental health records may be entitled to special confidentiality protections under applicable state or federal law. We will abide by these special protections as they pertain to applicable cases involving these types of records.

Treatment. We may use and disclose your health information for your treatment. For example, we may disclose your health information to a specialist providing treatment to you, or to a care provider that is overseeing other health needs you may have. Payment. We may use and disclose your health information to obtain reimbursement for the treatment and services you receive from us or another entity involved with your care. Payment activities include billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your dental health plan containing certain health information, or we could require a 3rd party to aid in collection of unpaid balances that are due. Healthcare Operations. We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, conducting training programs, and licensing activities. Individuals involved in Your Care or Payment for Your Care. We may disclose your health information to your family or friends or any other individual identified by you when they are involved in your care or in the payment for your care. Additionally, we may disclose information about you to a patient representative. If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information. Disaster Relief. We may use or disclose your health information to assist in disaster relief efforts. Required by Law. We will disclose your health information when we are required to do so by law. Public Health Activities. We may disclose your health information for public health activities as required by law, including disclosures to: Prevent or control disease, injury or disability; Report child abuse or neglect; Report reactions to medications or problems with products or devices; Notify a person of a recall, repair, or replacement of products or devices; Notify a person who may have been exposed to a disease or condition; or Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.

National Security. We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody the protected health information of an inmate or patient.

Secretary of HHS. We will disclose your health information to the Secretary of the U.S. Department of Health and Human Services when required to investigate or determine compliance with HIPAA.

Worker's Compensation. We may disclose your personal health information to the extent authorized by and to the extent necessary to comply with laws relating to worker's compensation or other similar programs established by law. Law Enforcement. We may disclose your personal health information for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order. Health Oversight Activities We may disclose your personal health information to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for the government programs, and compliance with civil rights laws. Judicial and Administrative Proceedings. If you are involved in a lawsuit or a dispute, we may disclose your personal health information in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about the request or to obtain an order protecting the information requested. Research. We may disclose your personal health information to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information. It should however be noted that we typically do not participate in research projects and this release is unlikely.
Coroners, Medical Examiners, and Funeral Directors. We may release your personal health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose personal health information to funeral directors consistent with applicable law to enable them to carry out their duties.
Fundraising. By law, we may contact you to provide you with information about our sponsored activities, including fundraising programs, as permitted by applicable law. If you do not wish to receive such information from us, you may opt out of receiving fundraising communications. Our office policy is to NOT fundraise with patient information.
Other Uses and Disclosures of Personal Health Information. If a situation arises that is not covered in the prior sections, we will seek your permission for health information disclosure, unless dictated to do so by law. Your privacy is important to us and we work hard to secure all patient health information to protect individual privacy.

YOUR HEALTH CARE RIGHTS
Access. You have the right to look at or get copies of your health information, with limited exceptions. You must make the request in writing. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice. If you request information that we maintain on paper, we may provide photocopies. If you request information that we maintain electronically, you still have the right to receive a printed, or if possible, an electronic copy. We will use the form and format you request if readily producible. We will charge you a reasonable cost­based fee for the cost of supplies and labor of copying, and for postage if you want copies mailed to you. Contact us using the information listed at the end of this Notice for any explanation of our fee structure. If you are denied a request for access, you have the right to have the denial reviewed in accordance with the requirements of applicable law.
Disclosure Accounting. With the exception of certain disclosures, you have the right to receive an accounting of disclosures of your health information in accordance with applicable laws and regulations. To request an accounting of disclosures of your health information, you must submit your request in writing to the Privacy Official. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to the additional requests.
Right to Request a Restriction. You have the right to request additional restrictions on our use or disclosure of your person health information by submitting a written request to the Privacy Official . Your written request must include (1) what information you want to limit, (2) whether you want to limit our use, disclosure or both, and (3) to whom you want the limits to apply. We are not required to agree to your request, except in the case where the disclosure is to a health plan for purposes of carrying out payment or health care operations, and the information pertains solely to a health care item or service for which you, or a person on your behalf (other than the health plan), has paid our practice in full.
Alternative Communication. You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. We will accommodate all reasonable requests. However, if we are unable to contact you using the ways or locations you have requested we may contact you using the information we have on file.
Amendment. You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. If we agree to your request, we will amend your record(s) and notify you of such. If we deny your request for an amendment, we will provide you with a written explanation of why we decided it and explain your rights.
Right to Notification of a Breach. You will receive notifications of breaches of your unsecured protected health information as required by law.
Electronic Notice. You may receive a paper copy of this Notice upon request, even if you have agreed to receive this Notice electronically on our Web site or by electronic mail (e-mail).
Questions and Complaints. If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or if you disagree with a decision we made about access to your health information or in response to a request you made to amend or strict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Privacy Practices Acknowledgement (All fields are required)

Privacy Notice Amendment September 2013

I have had the opportunity to read the Patient Privacy Notice for this practice. I understand that I may ask for a copy to take with me at any time, and that an appointed person is available to answer any questions that I may have now, or in the future, regarding the use on my Personal Health Information.

Foulk-Manela PC
7229 N Thornydale #149
Tucson, AZ 85741