Berwitz Special Needs New Patient Form

Patient Information

Patient Name

Social Security #

Birth Date

Email

Gender

Family Status

Phone - Home

Phone - Work (Ext.)

Best time to call

Preferred appointment times

Address (Street, Apt #, City, State, Zip Code)

Referral Information

Whom may we thank for referring you to our practice?

Name of person or office referring you to our practice:

Spouse or Responsible Party Information

The following is for:

The patient's spouse The other person responsible for payment

Name

Gender

Male Female

Birth Date

Relationship Status

Married Single Child other: ‎

Social Security #

Phone - Home

Phone - Work

Best time to call

Address (Street, Apt #, City, State, Zip Code)

Employment Information

The following is for:

The patient The other person responsible for payment

Employer Name

Occupation

Address (Street, Apt #, City, State, Zip Code)

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Dental Insurance Information

Primary Dental Insurance

Name of Insured

Is insured a patient?

Yes No

Birth Date

ID #

Group #

Address (Street, Apt #, City, State, Zip Code)

Employer Name

Employer Address

Dental Insurance Plan Name and Address

Dental Insurance Phone Number

Patient's relationship to insured

Self Child Spouse other: ‎

Secondary Dental Insurance

Name of Insured

Is insured a patient?

Yes No

Birth Date

ID #

Group #

Address (Street, Apt #, City, State, Zip Code)

Employer Name

Employer Address

Insurance Plan Name and Address

Insurance Phone Number

Patient's relationship to insured

Self Child Spouse other: ‎

Special Needs Patient Information

Patient Special Needs Diagnosis (ICD-10 Code) - Please check all that apply:

Has the patient had previous dental work in an office setting?

Yes No

Has the patient had previous dental work under sedation?

Yes No

Will the patient open their mouth for dental examination?

Yes No

Will the patient allow the doctor to take dental xrays in the office

Yes No

Preferred Pharmacy

Pharmacy Phone Number

Medical Insurance Information (Please provide copies of all cards at time of appointment)

Medical Insurance

If none, check here

‎

Medicare

If none, check here

‎

Medicaid

If none, check here

‎

Will you be using a WAIVER to cover the cost of dental treatment?

Yes No

Please check which waiver the patient has:
We are unable to process waiver requests unless NOW or COMP is selected. Please check with your Support Coordinator if you need assistance in identifying which waiver the patient has.

NOW‎ COMP‎

Case Manager

Name

Phone Number

Email

If not applicable, check here

‎

Family Contact

Name

Phone Number

Email

If not applicable, check here

‎

Legal Guardian

Name

Phone Number

Email

If not applicable, check here

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Support Coordinator

Name

Phone Number

Email

If not applicable, check here

‎

Consent for Services

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed.

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any such collections to patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

A service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.

I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.

After the patient’s dental assessment, it may be recommended that the patient’s treatment be completed under general anesthesia at Memorial University Medical Center. The reasons for this recommendation may include: extensive treatment needs, special health care/medical needs, and behavioral management or coping/cooperation difficulties.

To help you navigate your medical and dental benefits, we will gladly verify your insurance by sending a pre-authorization and we will provide you with an estimate for your out-of-pocket dental expenses. Please provide our office with all dental and medical insurance information, as well as waiver information, so that the proper paperwork can be submitted and processed prior to the patient’s treatment date.

The fee structure is such that there are 3 separate fees: one for the hospital and facilities, one for anesthesia, and one for the dental treatment. Your medical insurance should help cover portions of the first two fees (which will be billed by Memorial University Medical Center), and your dental insurance/dental treatment waiver will cover all/portions of the dental care (which will be billed through the dental office of Dr. Steven Berwitz). The patient is responsible for all non-covered expenses prior to treatment. To avoid cancellation/rescheduling of treatment, payment for dental services is due one-week prior to the patient’s scheduled appointment.

Anesthesia will be handled by an anesthesiologist at the Memorial University Medical Center. Anesthesia requires a history and physical (aka H&P or "pre-op") from the patient’s primary care physician signed and dated the day prior to the scheduled dental treatment date. It is important to contact the patient’s primary care physician soon after the patient’s initial dental assessment to verify if medical testing/clearance is required by any medical specialists (i.e., cardiologist, pulmonologist) prior to treatment.

I have read the above conditions of treatment and payment and agree to their content.

I have read the above conditions of treatment and payment and agree to their content.‎

Signature of patient, parent or guardian

Clear

Date

Relationship to Patient

Untitled

I have read the above conditions of treatment and payment and agree to their content.

Signature of guarantor of payment/responsible party

Clear

Date

Relationship to Patient

No-Show Policy

It is the policy of Steven G. Berwitz, DMD, P.C. to optimize the use of treatment time by working to ensure that scheduled time blocks are filled by scheduled patients. We understand that situations arise when you need to cancel an appointment. However, patients who do not provide the office with at least 24 hours’ notice of cancellation will be charged a $50.00 “No‐Show” fee for missing a confirmed appointment.

Steven G. Berwitz, DMD, P.C. reserve the right to discontinue patient care when an established patient misses three (3) confirmed appointments without providing one business day notice of cancellation. Established patients will be notified in writing that a third missed appointment will result in termination of the physician/patient relationship. When a new patient misses two (2) confirmed appointments, that patient will not be rescheduled. Thank you for your cooperation.

Untitled

I have read the above conditions.

Patient Signature

Clear

Date

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HIPAA Acknowledgement and Consent Form

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

- Conduct, plan and direct my treatment and follow‐up care among the multiple healthcare providers who may be involved in that treatment directly or indirectly.

- Obtain payment from designated third‐party payers.

- Conduct normal health care operations such as quality assessments or evaluations, and physician certifications.

I have been informed by you of the Notice of Privacy Practices; containing a more complete description of the uses and disclosures of my health information (available in office in print form or on the office website www.stevenberwitzdmd.com). I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address(es) below to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that this organization restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand the organization is not required to agree to my requested restrictions, but if the organization does agree, then it is bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that the organization has taken action relying on this consent.

Patient Name

Date of Birth

I have read the above conditions, and I DO consent to the terms. I have read the above conditions, but DO NOT consent to the terms.

Signature of Patient

Clear

Date

Legal Representative to Patient

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Health History Form

Email

Date

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Name

Home Phone

Business/Cell Phone

Address (Street, Apt #, City, State, Zip Code)

Occupation

Height

Weight

Date of Birth

Sex

SS# or Patient ID

Emergency Contact

Relationship

Home Phone

Cell Phone

If you are completing this form for another person, what is your name and relationship to that person?

Check the boxes for any of the following diseases or problems you may have.

Active Tuberculosis‎ Cough that produces blood‎ Been exposed to anyone with tuberculosis‎ Persistent cough greater than a 3 week duration‎

Dental Information
Please check any of the following boxes that apply to you.

Untitled

Date of your last dental exam

Date of last dental x-ray

What was done at last dental exam?

What is the reason for your dental visit today?

How do you feel about your smile?

Medical Information

You are currently under the care of a physician

Yes No

Physician Name and Address

Date of last physical exam

Has there been any change in your general health within the past year?

Yes No

If yes, what condition is being treated?

Have you had a serious illness, operation or been hospitalized in the past 5 years?

Yes No

If yes, what was the illness or problem?

Are you taking or have you recently taken any prescription or over the counter medicine(s)?

Yes No

If so, please list all, including vitamins, natural or herbal preparations and/or diet supplements:

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Medical Information

You have had an orthopedic total joint replacement

Yes No

Date

Complications?

Y N

You are taking or scheduled to begin taking either of the medications, alendronate (Fosamax) or risedronate (Actonel) for osteoporosis or Paget's disease

Yes No

Since 2001, you were treated or are presently scheduled for treatment with the intravenous bisphosphonates (Aredia or Zometa) for bone pain, hypercalcemia or skeletal complications resulting from Paget's disease, multiple Myeloma or metastatic cancer

Yes No

Do you use tobacco (smoking, snuff, chew, bidis)?

Yes‎ No‎

If so, how interested are you in stopping?

Very‎ Somewhat‎ Not interested‎

You wear contact lenses

Yes No

Women Only

You are pregnant‎ You take birth control pills or hormonal replacement‎ You are nursing‎

Allergies - Please check any of the following boxes that apply to you.

Please check the box if you have had any of the following diseases or problems.

Do you have or have you had congenital heart disease (CHD)? If so, please specify:

Unrepaired, cyanotic CHD Repaired (completely) in last 6 months Repaired CHD with residual defects

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

Yes No

Name and phone number of physician or dentist making recommendation

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Signature of Patient/Legal Guardian

Clear

Date