PATIENT REGISTRATION

ID:

First Name:

Patient Is:

Chart ID:

1 Policy Holder

Last Name:

Preferred Name:

Middle Initial:

[J Responsible Party

Responsible Party (if someone other than the patient)

First Name:

Address:

City, State, Zip:

Home Phone:

Birth Date:

e patient)—

Last Name: Middle Initial:

Address 2:

Pager:

Work Phone: Ext:

Soc Sec: Drivers

Jer for Patient O Primary Insurance Policy Holder

Cellular:

Lie:

O Secondary Insurance Policy Holder

Patient Information

Address:

City:

Address 2:

State/Zip: Pager

Home Phone: Work Phone: Ext: Cellular:

Sex: Q Mate

Birth Date:

E-mail:

O Female

Age:

Marital Status: O Married O Single

Soc. Sec:

O Divorced Q Separated O Widowed

Drivers Lie:

Section 2

Employment Status: Q Full Time Q Part Time Q Retired-f4»; •"" - ,<(

Student Status: Q Full Time Q Part Time ,

Medicaid ID: Pref. Dentist: '

] I would like to receive correspondences via e-mail.

Section 3Emergency Contact:

Emergency Phone #:

Employer ID:

Carrier ID:

Pref. Pharmacy:

Pref.Hyg.:

Primary Insurance Information-

Name of Insured:

Insured Soc. Sec:

Employer:

Relationship to InsuredQ Self Q Spouse Q Child

Insured Birth Date:

Ins. Company:

Address:

Address 2:

City.State.Zip:

Rem. Benefits:

Address:

Address 2:

City.State.Zip:

.00 Rem. Deduct: .00

—Secondary Insurance Information

Name of Insured:

Insured Soc. Sec:

Employer:

Relationship to InsuredO Self Q Spouse Q Child O Other

Insured Birth Date:

Ins. Company:

Address:

Address 2:

City.State.Zip:

Rem. Benefits:

Address:

Address 2:

City.State.Zip:

.00 Rem. Deduct: .00

Laila Bellinger DOS, PC

MEDICAL HISTORY

PATIENT NAME Birth Date

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you mayhave, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering thefollowing questions.

If yes, please explain: _If yes, please explain:If yes, please explain:If yes, please explain:

Are you under a physician's care now? O Yes O NoHave you ever been hospitalized or had a major operation? Q Yes O No

Have you ever had a serious head or neck injury? O Yes O NoAre you taking any medications, pills, or drugs? O Yes O No

Do you take, or have you taken, Phen-Fen or Redux? O Yes O NoHave you ever taken Fosamax, Boniva, Actonel or any /-\ y ON

other medications containing bisphosphonates? (~

Are you on a special diet? O Yes Q NoDo you use tobacco? O Yes O No

Do you use controlled substances? O Yes O NoWomen: Are youPregnant/Trying to get pregnant? O Yes O No Taking oral contraceptives? Q Yes Q No Nursing? Q Yes Q No

Q Aspirin [

[J Other If yes,

any of the follov

] Penicillin

please explain:

/ing?

Q Codeine Q Local Anesthetics | | Acrylic n Metal n Latex Q Sulfa drugs

Do you have, or have you had, any oAIDS/HIV Positive O Yes Q NoAlzheimer's Disease O Yes O NoAnaphylaxis O Yes O NoAnemia O Yes O NoAngina O Yes O NoArthritis/Gout Q Yes O NoArtificial Heart Valve Q Yes O NoArtificial Joint O Yes O NoAsthma O Yes O NoBlood Disease O Yes O NoBlood Transfusion Q Yes O No

Breathing Problem Q Yes O NoBruise Easily O Yes O NoCancer O Yes O NoChemotherapy O Yes O NoChest Pains O Yes O NoCold Sores/Fever Blisters O Yes O NoCongenital Heart DisorderQ Yes O No

f fUd fntlruAfinnOtne Toiiowing f "̂

Cortisone Medicine «r O Yes Q NoDiabetes ' Q Yes Q NoDrug Addiction -. ~ O ; Yes-O No.Easily Winded O Yes Q NoEmphysema O Yes O No

Epilepsy or Seizures O Yes O NoExcessive Bleeding O Yes O NoExcessive Thirst O Yes O No

Fainting Spells/Dizziness O Yes O NoFrequent Cough O Yes O NoFrequent Diarrhea Q Yes O NoFrequent Headaches O Yes 0 NoGenital Herpes O Yes Q NoGlaucoma O Yes O NoHay Fever Q Yes Q NoHeart Attack/Failure Q Yes Q NoHeart Murmur O Yes 0 NoHeart Pacemaker O Yes O No

Hemophilia Q Yes Q N°Hepatitis A Q Yes Q NoHepatitis B or C Q Yes O NoHerpes Q Yes Q NoHigh Blood Pressure Q Yes O NOHigh Cholesterol Q Yes Q NoHives or Rash O Yes O NoHypoglycemia O Yes O NoIrregular Heartbeat O Yes Q NoKidney Problems O Yes Q NoLeukemia O Yes O NoLiver Disease Q Yes Q No

Low Blood Pressure O Yes Q NoLung Disease Q Yes O No

Mitral Valve Prolapse O Yes O NoOsteoporosis Q Yes O NoPain in Jaw Joints O Yes O NoParathyroid Disease O Yes O No

Radiation TreatmentsRecent Weight LossRenal DialysisRheumatic FeverRheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSpina Bifida

O Yes O NoO Yes O No :O Yes O No iO Yes O No iO Yes O NoO Yes O NoO Yes O No iO Yes O NoO Yes O NoO Yes O No

Stomach/Intestinal Disease O Yes Q NoStrokeSwelling of LimbsThyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersVfinRrpal Disease

Convulsions O Yes O No Heart Trouble/Disease Q Yes O No Psychiatric Care (J Yes (J) No YeMawJaundSce"

Have you ever had any serious illness not listed above? O Yes O No1 _ _

O Yes O NoQ Yes O No :O Yes O No :

O Yes O No iO Yes O NoO Yes O No !O Yes O No ;O Yes O No :

O Yes O No

Comments:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can bedangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

SIGNATURE OF PATIENT, PARENT, or GUARDIAN. DATE

Financial Policy •

The following financial arrangements are available. Please indicate your choice of payment by checkingOption A, B, or C below.

OPTION A PAYMENT IN FULL AT TIME OF SERVICE

Payment is expected at time of treatment by:1-1 /-iD CashQ CheckD Credit Card - Visa/Mastercard/Discover

OPTION B COVERAGE BY DENTAL OR MEDICAL INSURANCE .

In many cases we are able to accurately predetermine and estimate your insurance coverage, deductible andco-insurance. Your deductible and co-insurance are due at the time of service. After your insurancecompany has made payment, any remainder due to us by you is then considered payable in full by you atthat time. Options A (above) and C (below) are available for payment of those fees.

Any overpayment by you or your insurance will be refunded after the account has been paid in full.

FOR PATIENTS WITH MEDICAID (TITLE 19)

DD

The co-payment as directed by Medicaid (title 19) is required at the time of service.Charges for services not covered by Medicaid (title 19) are your responsibility. Options A(above) and C (below) are available for payment of those fees.

OPTION C PAYMENT PLANS/FINANCING TREATMENT FEES OR BALANCES

Patients wishing to finance treatment fees may be eligible for payment plans/financing through an outsidelender (Care Credit, Wells Fargo or other). Please request details from the Receptionist or Office Manager.

.

-

PLEASE NOTE1. Account balances 60 days past the date of service will be charged interest at the rate of 1.5% monthly (18% APR).2. If 90 days have passed since your last payment, your account may be turned over to legal counsel and/or small claims.3. Should the account be referred for collection or small claims, the patient or responsible party shall pay reasonable

attorney's fees and collection expenses.4. A fee of $30 (or maximum allowable by law), will be assessed to all accounts with returned checks.5. A 24 hour notice is required for all cancellations or rescheduled appointments. Failure to notiiy us in the required time

frame is considered a failed appointment. One failed appointment may result in a service fee and three failedappointments may result in patient dismissal.

As a courtesy to our patients, we will file insurance claims for you with the information you provided.However, our professional services are rendered to you and not to the insurance company; therefore you aredirectly responsible to us for the cost of your treatment. My signature below hereby assigns all benefits toLaila Bellinger D.D.S., P.C. that would otherwise be payable to me under the dental expense provision ofthe above named dental insurance policies.

"By scheduling an appointment, I acknowledge and agree to the financial policy and will be responsible forpayment as outlined above."

Signature Date•

Notice of Privacy Practices for Protected Medical/Dental InformationLaila Boilinger D.D.S., P.C.

. . .This notice describes how medical/dental information about you may be

used and disclosed and how you can get access to this information. Please review it carefully!

With your consent, the practice is permitted by federal privacy laws to make uses and disclosures of your medical and medical/dental information forpurposes of treatment, payment, and medical/dental operations. Protected medical/dental information is the information we create and obtain in providingour services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying forfuture care or treatment. It also includes billing documents for those services. •

Example of uses of your medical/dental information for treatment purposes:A hygienist obtains treatment information about you and records it in a medical/dental record. During the course of your treatment, the doctor determinesa need to consult with another specialist in the area. The doctor will share the information with such specialist and obtain input. An employee may alsocall to remind you of an upcoming appointment and leave a message on your answering machine unless you notify the office that you object to suchmessages. Additionally, a postcard may be mailed to remind you of an upcoming appointment or the need for you to make an appointment.

Example of use of your medical/dental information for payment purposes:We submit a request for payment to your medical/dental insurance company. The medical/dental insurance company may request information from usregarding medical/dental care given. We will provide information to them about you and the care given.

Example of Use of Your Information for Medical/dental Care Operations:We obtain services from our insurers or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol andclinical guidelines development, training programs, credentialing, medical/dental review, legal services, and insurance. We will share information aboutyou with such insurers or other business associates as necessary to obtain these services.

Your Medical/dental Information Rights .The medical/dental record we maintain and billing records are the physical property of the practice. The information in it, however, belongs to you.

You have a right to:* Request a restriction on certain uses and disclosures of your medical/dental information by delivering the request in writing to our office. We are notrequired to grant the request but we will comply with any request granted;* Request that you be allowed to inspect and copy your medical/dental record and billing record-you may exercise this right by delivering the request inwriting to our office; We will charge you a reasonable fee for expenses such as copies and staff time. If you request copies, we will charge you $ 1 .(X) foreach page for staff time to loeate and copy your information, in addition to postage if you want the copies mailed to you.* Appeal a denial of access to your protected medical/dental information except in certain circumstances:* Request that your medical/dental care record be amended to correct incomplete or incorrect information by delivering a written request to our office;* File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all futuredisclosures of your protected medical/dental information:* Obtain an accounting of disclosures of your medical/dental information as required to be maintained by law by delivering a written request to ouroffice. An accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at yourrequest, or disclosures made to family members or friends in the course of providing care;* Request that communication of your medical/dental information be made by alternative means or at an alternative location by delivering the request inwriting to our office: and,* Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken bydelivering a written revocation to our office.• • • .- .• . . . . " • • • • . -

If you want to exercise any of the above rights, please contact Office Manager Jim Boilinger. in person or in writing, during normal hours. He willprovide you with assistance on the steps to take to exercise your rights.

' ' . ' • / ; ' • -

Our ResponsibilitiesThe practice is required to;* Maintain the privacy of your medical/dental information as required by law;* Provide you with a notice of our duties and privacy practices as lo the information we collectand maintain about you;* Abkle by the terms of this Notice;* Notify you if we cannot accommodate a requested restriction or request: and

• Accommodate your reasonable requests regarding methods to communicate medical/dentalinformation with you.

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisionsregarding the protected medical/dental information we maintain. If our information practices change, we will amend our Notice. You areentitled to receive a revised copy of the Notice by calling and requesting a copy of our "Notice" or by v isiting our office and picking up a copy.

To Request Information or File a ComplaintIf you have questions, would like additional information, or want to report a problem regarding the handling oi your information, you maycontact Jim Boilinger at 641-585-4636 or 132 1-asi J Street. I'-'ore.st City. IA 50436.

Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the writtencomplaint to the above address. You may also file a complaint by mailing it ore-mailing it to the Secretary of Medical/dental and HumanServices.

Other Disclosures and Uses.

NotificationUnless you object, we may use or disclose your protected medical/dental information to notify, or assist in notifying, a family member,personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.

Communication with FamilyUsing our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify,medical/dental information relevant to that person's involvement in your care or in payment for such care if you do not object or in anemergency.

Food and Drug Administration (FDA)We may disclose to the FDA your protected medical/dental information relating to adverse events with respect to products and product defects,or post-marketing surveillance information to enable product recalls, repairs, or replacements.

Workers CompensationIf you are seeking compensation through Workers Compensation, we may disclose your protected medical/dental information to the extentnecessary to comply with laws relating to Workers Compensation.

Public Medical/dentalAs required by law, we may disclose your protected medical/dental information to public medical/dental or legal authorities charged withpreventing or controlling disease, injury, or disability.

- .Abuse & NeglectWe may disclose your protected medical/dental information to public authorities as allowed by law to report abuse or neglect.

Correctional InstitutionsIf you are an inmate of a correctional institution, we/rnay disclose to the institution, or its agents, your protected medical/dental informationnecessary for your medical/dental and the medical/dental and safety of other individuals.

Law EnforcementWe may disclose your protected medical/dental information for law enforcement purposes as required by law, such as when required by a courtorder, or in cases involving felony prosecutions, of to the extent an individual is in the custody of law enforcement.

Medical/dental OversightFederal law allows us to release your protected medical/dental information to appropriate medical/dental oversight agencies or formedical/dental oversight activities.

Judicial/Administrative ProceedingsWe may disclose your protected medical/dental information in the course of any judicial or administrative proceeding as allowed or required bylaw. with your consent, or as directed by a proper court order.

Other UsesOther uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with your writtenauthorization and you may revoke the authorization as previously provided!

**You may refuse to sign this acknowledgement**

Name (please print):

I hereby acknowledge 1 have read the above. I have been given an opportunity to ask any questions I have regarding this notice. I have been giventhe opportunity to receive a personal copy of the Notice of Privacy Practices should I desire one.

Signature: Date:

For Office Use OnlyWe attempted to obtain written acknowledgement of our privacy and financial practices. Acknowledgement could not he obtained because:

o Individual refused to signo Communication barriers prohibit obtaining the acknowledgemento An emergency situation prevented us from obtaining acknowledgemento Other