Patient Registration Form

General Office Information

Practice Administrator: Stacy Demchock

Services

Patient’s Rights & Responsibilities

Patient’s Bill of Rights

• Considerate, respectful, and timely care without any discrimination that meets or exceeds the Standard of Care.
• Be treated in a safe, clean, and smoke-free environment.
• Privacy concerning your dental treatment. Discussions concerning your care will remain confidential between you and the doctors and staff at Cornerstone Dental of Henrietta. No information will be disclosed regarding your treatment without your prior written authorization, unless required by law.
• Receive current and complete information regarding the diagnosis and treatment of your dental condition(s), including its prognosis, in terms you can understand.
• Know the detailed treatment plan, alternatives, risks and benefits concerning your dental condition, along with the estimated cost of such treatment, sufficient to give us your informed consent before any treatment is started.
• Participate in all decisions about your treatment.
• Refuse treatment suggested for you and the right to know the risks of refusal.
• Expect that your care meets the Standards of Care of the dental profession.
• Prompt treatment and continuing care after you have reached a maintenance level including follow-up care.
• Continuity and completion of your dental treatment. You have the right to emergency care as needed.
• Access to your dental records upon request and to have the information explained or interpreted.
• Request and examine any financial statement regarding your treatment.

Patient Responsibilities

• Provide, to the best of your knowledge, complete and accurate information regarding your present health, past illnesses and hospitalizations, medications, dental concerns, and any other matters pertaining to your health.
• Report any changes in your health since your last appointment to your hygienist and/or dentist.
• Inform us if you do not fully understand your dental condition, the proposed treatment to be rendered, the risks and benefits associated with the proposed treatment and alternatives to your proposed treatment, and associated fees.
• Follow any and all recommended instructions, including preventive home care techniques and follow-up treatment, given to you.
• Be prompt for your scheduled appointments. We reserve specific time for you and make every effort to respect that your time is valuable. If you are unable to make a scheduled appointment please contact us with 48 hours notice.
• Discharge your financial obligations to Cornerstone Dental of Henrietta. This includes disclosing information for changes in insurance carrier or discontinuation of dental insurance.
• Ensure that the financial obligations of your care are fulfilled as promptly as possible.
• Ask questions when you do not understand information or instructions given to you.
• Be considerate of the rights of other patients by controlling noise and respecting a smoke-free environment.
• Bear the responsibility for any harm to your oral health or untoward reactions that may result from the refusal of treatment, although it is your right to refuse proposed treatment.

CORNERSTONE DENTAL OF HENRIETTA, PLLC - NOTICE OF PRIVACY PRACTICES

This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. We are required by law to maintain the privacy of protected health information or PHI, 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. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect September 1, 2013, and will remain in effect until we replace it.

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 law, 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, and we will provide copies of the new Notice upon request. You may request a copy of our Notice at any time. 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. The privacy of your health information is important to us.

USES AND DISCLOSURES OF HEALTH INFORMATION

Treatment.

Payment.

Healthcare Operations.

Individuals Involved in Your Care or Payment for Your Care.

Disaster Relief.

Required by Law.

Judicial and Administrative Proceedings.

Research.

Coroners, Medical Examiners, and Funeral Directors.

Public Health Activities.

• 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.

Secretary of HHS.

Worker’s Compensation.

Law Enforcement.

Health Oversight Activities.

Fundraising.

Other Uses and Disclosures of PHI.

YOUR HEALTH INFORMATION RIGHTS

Access.

Disclosure Accounting.

Right to Request a Restriction.

Alternative Communication.

Amendment.

Right to Notification of a Breach.

Electronic Notice.

QUESTIONS AND COMPLAINTS

Office Appointment Policy

• Any recent x-rays taken in the last year at other offices. If unavailable, we may take our own x-rays.
• All medical information including any medications, surgeries, etc.

Missed or Cancelled Appointments

A charge may be assessed for multiple missed or “short notice” rescheduled/cancelled appointments. Multiple failed appointments may erode the doctor-patient relationship and result in being dismissed from the practice.

Broken or cancelled appointments with less than the required 48-hour (2 working days) notice in a 6-month period may result in the following charges:

• 1st broken or “short notice” rescheduled/cancelled appointment:
• No charge
• 2nd broken or “short notice” rescheduled/cancelled appointment:
• Hygiene appointment: $25 charge
• Dentist appointment: $50 charge
• 3rd broken or “short notice” rescheduled/cancelled appointment:
• Hygiene appointment: $50 charge
• Dentist appointment: $100 charge
• Account will be reviewed and continued care will be at the discretion of your primary oral health care provider

I certify that I have read this policy, or that it has been read to me, and that I understand the above. I have had an opportunity to ask questions and had these questions addressed to my satisfaction.

Office Financial Policies, Insurance & Assignment of Benefits

1. Before any treatment is performed, we will discuss treatment options to include the risks and benefits of each, as well as financial options. This will help you to fully understand your dental treatment, what to anticipate in fees, and allow you time to make any necessary financial arrangements.
2. Payment is due at the time service is provided.
3. Treatment Plans may change, but you are responsible for the treatment actually completed.
4. Large cases (≥$1000) as well as cases associated with lab services require a down payment or “reservation fee” prior to starting treatment.
5. Our office accepts the following payment options:
   • Cash
   • Personal checks (additional fees will be applied for returned checks)
   • Visa, MasterCard, Discover, American Express
   • Third-party financing such as CareCredit (available upon request and approval)
   • Payment Plan Options (requires approval)
6. Any/all account balances over 90 days are subject to a $35.00 late fee.
7. Accounts where payment arrangements are in default are subject to a $35.00 fee.
8. A $35.00 charge will be billed to accounts for any returned checks by the bank for any reason.
9. If sent to Collections due to non-payment, you agree to pay any/all related legal fees and court costs.

As a courtesy to you, we will process all of your dental insurance claims and do all that we can to help you maximize your insurance benefits. We will provide you with an estimate regarding reimbursement, but cannot guarantee coverage for recommended or provided procedures due to the complexities of insurance contracts. Insurance coverage is subject, but not limited to, plan limitations, exclusions, waiting periods, frequency restrictions, age restrictions, deductibles and maximums. These are parameters within your plan, out of our control, and ultimately between you and your insurance company. Please contact your insurance company for a detailed breakdown of your benefits.

Your insurance company and your plan benefits ultimately determine the amount paid. We will do all we can to ensure your estimate is as accurate as possible, however, your estimated insurance benefit may differ due to a number of reasons, specifically related to your plan.

• All charges you incur are your responsibility, regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you and your insurance company. Our office is not a party to that contract.
• Our practice is committed to providing the best treatment for our patients and our fees are considered usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.
• We ask that you sign this form and/or any other necessary documents that may be required by your insurance company. This form allows us to release your treatment information to your insurance company and instructs your insurance company to make payment directly to our office (when indicated/applicable). By signing this Financial Policy, you authorize the release of any information concerning you (or your child’s) health care advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits.
• When indicated, we ask that you pay any deductible, co-payment and co-insurance, which is the estimated amount not covered by your insurance company, by cash, check, MasterCard, Visa, Discover, American Express or 3rd party financing (ie. CareCredit) at the time we provide service to you.
• Insurance payments are ordinarily received within 30-60 days from the time of filing a claim. If your insurance company has not made payment within 60 days, we will ask that you contact your insurance company to make sure payment is expected. If payment is not received or your claim is denied, you will be responsible for paying the full amount.
• We will cooperate fully with the regulations and requests of your insurance company that may assist in the claim being paid. Our office will not, however, enter into a dispute with your insurance company over any claim.

The parent or legal guardian accompanying a minor, who has consented to treatment, is responsible for full payment at time of service.

***Unaccompanied Minors: The parent or legal guardian is responsible for full payment at time of service. Treatment consents and payment arrangements with the parent or legal guardian must be made prior to appointment or nonemergency treatment may be denied.

Informed Consent for Dental Procedures

You the patient have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedures, alternative treatments, or the option and risks of no treatment.

It is very important that you provide your dentist with accurate medical and situational information before, during and after treatment. It is equally important that you follow your dentist’s advice and recommendations regarding medication, pre and post treatment instructions, referrals to other dentists or specialists, and return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome.

If you are a woman on oral birth control medication you must consider the fact that antibiotics might make oral birth control less effective. Please consult with your physician before relying on oral birth control medication if your dentist prescribes, or if you are taking antibiotics.

Please do not consent to treatment unless and until you discuss potential benefits, risks, and complications with your dentist and all of your questions are answered to your satisfaction. By consenting to treatment, you acknowledge your willingness to accept known risks and complications, no matter how slight the probability of occurrence.

CONSENT:

Informed Consent/Authorization for
Use and Disclosure of Patient Name, Photographs, Voice, and/or Video Images

We pride ourselves on being a fun, friendly, and dynamic office. We frequently take pictures and videos and post to our website as well as to social media sites, such as Facebook and Instagram, to show off the services we provide and the results we get. Thank you for choosing Cornerstone Dental of Henrietta, PLLC for all your oral health care needs and for agreeing to help us!

Authorization:

Before & After Photos:

Research, Training, Lectures, or Case Studies:

Promotions / Marketing (Website, Facebook, Instagram, Brochures, Contests, etc.):

Purpose:

The photographic or video images, voice recordings, testimonials or biographic information may be used in any of the following manners: Internet websites, social media, print, digital, television or internet for advertising or marketing.

Revocability:

No Treatment Conditions:

ACKNOWLEDGEMENT OF PRIVACY PRACTICES

Cornerstone Dental of Henrietta, PLLC’s Notice of Privacy Practices provides information about how protected health information (PHI) about me (the patient) may be used or disclosed. I have been offered an opportunity to review the Notice, object to the use or disclosure of my PHI, and/or request restrictions as to how my PHI may be used or disclosed for treatment, payment, or healthcare operations before signing this consent. Cornerstone Dental, LLP is not required to agree to any restrictions, but if they agree, will be bound by the agreement. I understand that the terms of the Notice may change and I may obtain a revised copy by contacting the office at (585) 865-7030 or by visiting the office’s website at www.cornerstonedentalny.com.

FOR OFFICE USE ONLY

Attempts were made to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but could not be obtained because: