Morrison Dental Associates

Patient Information

								
								First Name
							
								Last Name
							
								Middle Name
							
								Date Of Birth
							
									Gender:
									
										Male
									
										Female

Parent / Guardian Information

								
								Parent / Guardian Name
							
								Date of Birth
							
								Social Security Number
							
								Address
							
								Apt#
							
								City
							
								State
							
								Zip
							
								Email Address
							
								Home Phone
							
								Cell Phone
							
								Employer
							
								Employer's Phone
							
								In the event of an emergency who should we contact?
							
								Relationship
							
								Emergency Contact Phone

Child's Medical History

Does your child have a Physician? Yes No

Physician's Name

Physician's Phone

May we have permission to contact your child's physician if necessary? Yes No

Is your child up to date on immunizations? Yes No

Does your child snore? Yes No

Does your child have exposure to tobacco smoke? Yes No

Does your child wet the bed? Yes No

Has your child ever been hospitalized, had surgery, or beeh treated in the emergency department? If yes, explain.

Please list all medications (prescriptions or OTC) vitamins and/or suppliments child is currently taking.

Other allergies? Please list:

I, the undersigned, do hereby authorize Morrison Dental Associates, PC to exam and treat the patient as deemed necessary by the dentist. If the undersigned is not the patient, he/ she assumes all responsibility for the accurateness of the medical and dental information furnished on this form. I further affirm that the medical and dental information is correct, and the patient does not have any communicable disease which would be infectious to those providing services for him/her or others coming in contact with the patient in the office. This authorization is good for two years.

Parent / Guardian Signature

Date

If the information on the first page does not belong to the person signing the form above, please fill out the tollowing.

									
									Print name of signer
								
									Relationship to patient
								
									Address of signer
								
									City
								
									State
								
									Phone Number
								
									Employer
								
									Employer's Phone Number

Patient/Provider Agreement

This is to advise you that Morrison Dental Associates, P.C. is privately owned and operated. As providers of care and owners of this corporation, we reserve the right to discontinue services to patients who:

Are unwilling to follow medical recommendations or treatment plans.
Are unwilling to schedule recommended follow-up visits or tests as prescribed by our providers or repeatedly miss scheduled appointments.
Use vulgar, demanding or abusive speech towards our staff, providers, or other visitors to our facility.
Demonstrate abuse of medication, equipment or supplies.
Damage our property or grounds.
Display threatening behavior (by phone or in person) of any kind toward staff, providers or other visitors to our practice.
Enter the clinical areas unescorted or otherwise violates patients' privacy act as outlined under HIPPA.
Are disrespectful of the needs of other patients visiting our practice.

In Addition to the above, should any visitor accompanying a patient display any of the above behaviors, we reserve the right to discontinue service to the patient. We feel the above actions are necessary to ensure a friendly, safe and secure environment as well to ensure respectful and efficient business operations.

Minor Patients: A parent or legal guardian must accompany all minors before treatment can be provided.

Your initials indicate your understanding of this policy.

Date

Dental Insurance

If you wish to file dental insurance or Medicaid please tell the receptionist so we can obtain the information necessary to file for you.

The undersigned understands that insurance or Medicaid coverage does not relieve him/her of the responsibility of payment of the entire account if third party payment is not received. Estimates given by our staff are not a guarantee of the insurance or Medicaid payments as these third parties will not guarantee payments until a claim is received. Estimates are based on information we have at the time regarding your coverage.

We will bill participating insurance companies as a courtesy to you. Therefore, we will request a copy of your insurance card at each visit. Please understand that insurance is a contract between you and your carrier. Therefore, you are ultimately responsible for your bill. You are responsible for knowing the coverage, limitations, waiting periods, and exclusions specific to your insurance policy.

The undersigned is responsible for the payment of services rendered in addition to the head of household. If the patient is a minor BOTH parents are responsible. If the undersigned is not the patient it is understood that the patient is also responsible for payment of services provided for him/her.

In event of nonpayment resulting in default of the account should Morrison Dental Associates, PC refer this account to an attorney, I agree to pay and indemnify Morrison Dental Associates, PC against legal cost and charges including, but not limited to, reasonable attorney's fees, court cost and disbursements. I further grant permission to release information contained on this information sheet to any attorney in order to collect the amount due. Interest shall accrue on the account at the rate of 1.5% per month, 18% annum, on the unpaid balance. Payment in-full is due at the time of service. Any account not paid at the time of service is due in-full within thirty (30) days of services. If account is not paid at the time of service, Morrison Dental Associates, PC is authorized to obtain a report from a credit reporting agency regarding my credit history.

*** Member Equifax Credit Reporting Services ***
As required by law, you, herby notified that a negative credit report reflecting on your credit records may be submitted to a credit reporting agency if you fail to fulfill the terms of your credit obligations.

If insured through Georgia Health Partnership (Medicaid/Medicare)
Georgia Health Partnership requires all insurance claims to be filed through private insurance before they will accept the claim. I understand that failing to provide private insurance information will result in Medicaid/Medicare denying services and therefore I will be responsible for all charges. Medicaid Medicare

Does patient have private insurance?
(If yes please provide receptionist with the insurance information) Yes No

Child's Name

Date Of Birth

							
							Insurance Company
						
							Insurance Company Address
						
							Insurance Company Phone Number

							
							Member ID #
						
							Group #
						
							Policy #

Relationship to insured: Self Spouse Child Dependent

							
							Insured's Name
						
							Date Of Birth
						
							Insured's Social Security Number

Employer

Employer's Phone

Parent / Guardian Signature

Date

HIPAA Patient Consent Form

The Department of Health and Human Services has established a "Privacy Rule" to help ensure the personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patient's consent for uses and disclosures of health information about the patient, to carry out treatment, payment, or health care operations.

As our patient, we want you to know that we respect the privacy of your personal dental records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment or health care operations, in order to provide health care that is in your best interest.

We also want you to know that we support our full access to your personal dental records as provided by the Georgia Code. We may have indirect treatment relationships with you (such as laboratories that only interact with doctors and not patients) and may have to disclose personal health information for purposes of treatment, payment or health care operations. These entities are most often not required to obtain patient consent.

You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you, should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in the document, at some future time, you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken, which relied on this or a previously signed consent.

If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer.

You have the right to review our privacy notice, to request restrictions and revoke consent, in writing, after you have reviewed our privacy notice.

Patient's Name

Date

								
								Print Name of Person Signing
							
								Parent / Guardian Signature
							
								Witness Signature

HIPAA Release Form

I (PATIENT / GUARDIAN NAME below) authorize the release of information of the patient.

Print Patient / Guardian Name

The information of (PATIENT NAME below) including the diagnosis, records, examination and treatment rendered to above patient, ledger and billing, and claims information.

Patient Name

This information may be released to (check those that apply):

Spouse

Child(ren)

Other

None

If this information may be released to SPOUSE, please type spouse's name

Spouse's Name

If this information may be released to CHILD(REN), please type children's name

Children's Name

If this information may be released to OTHER, please type a name

Other Person's Name

Note:
In further consideration for this, Morrison Dental Associates, PC. Agrees to the same stipulations. This release of information will remain in effect until terminated by me in writing.

Messages and communication from our office.

If we are unable to speak directly to you concerning matters pertaining to your care, please check one of the following preferences:

You may leave a detailed message

Please leave a message asking me to return your call

Other (please specific method below)

Other method

The best phone number to reach me

Parent / Guardian Signature

Date

Witness

Date

Select Referrer

Please select the dental office you want this form to send to:

Child Medical Form

Patient Information

Parent / Guardian Information

Child's Medical History

Patient/Provider Agreement

Dental Insurance

HIPAA Patient Consent Form

HIPAA Release Form

Select Referrer