Mark Klopenstine, D.D. S.

Shiland Dentistry
Mark R. Klopenstine, DDS
2460 lndia Hook Rd, Suite 207
Rock Hill, 5C29732
JoyW. Dixon, DMD
Mark Klopenstine, D.D.
S.
Welcome to Shiland Dentistry!
Enclosed is our Patient Package Forms. Please complete these so we can maintain accurate contact
and medical records and assist with your dental insurance filling. Please bring the completed forms with
you to your appointment.
We are pleased that you have chosen our practice for your dental care. We realize that you have a
choice of where to be treated. As a caring team of dental professionals, our mission is to provide an
exceptional experience for our patients while utilizing the most advanced technology to accommodate
your dental needs. We will do our best to give you total satisfaction.
Thank you for your time and help in completing these forms. We place a high value on our relationship
with our patients. lf you have questions or concerns, please feel free to contact our office at
(803) 328-8004 or speak to any member of our team. We look forward to seeing you and caring for your
dental needs.
Warmest Regards,
Mark R. Klopenstine, DDS
Joy W. Dixon, DMD
Reminders of Required ltems for Your Visit
c
o
r
o
o
Completed Patient Package Forms
lnsurance Card. lf we do not have your insurance cardiinformation prior to your service, it will be
necessary for us to collect payment in full at time of visit.
Patient estimated portion of service (cost of service that insurance will not pay), unless previously
written financial arrangements are satisfied.
Parent or legal guardian must accompany patients who are minors.
lf you are unable to keep your appointment, please call to cancel or a $50.00 fee may be applied
to your account.
2460lndiaHookRoad' Suite207' RockHill' SC
. 29732. Phone803-328-8004.
www.shilanddentistry.com
Dental lnfonnation
visit tl
Reason for today's
tr Consultation E
Exam
Emergency
tr Other Date of Last Dental Visit:
Please indicate any of the following problems or concems:
tr Cosmetic questions or concerns tr Broken/chipped filling/tooth tr Sensitive to hoUcoldlsweets
tr Discomfort, clicking or popping jaw tr Teeth clenching/grinding tr Red, swollen or bleeding gums
trSensitivity when
biting
B
Bad
Breath
tr Periodontal Disease
lf you could change anything about your mouth, teeth, or smile, what would it be?
Have you had instructions for the proper methods of brushing and flossing? tr
Times a day you 'brush?
Times a wmk you floss?
_
_
Yes
tr No
Health lnformation._
#=
s Are you now under the regullr care of a physician? tlYes Il No '
s Family
Physician:
Phone
,.
lf yes, please explain:
s Have you had any major opratiohsl hospitalization or
lf yes, please explain and provide dates:
,
s Have you ever had any complications following dental treatment? B Yes
lf yes, please explain:
s Do you smoke? B Yes
tr No
'
illnesses?
tr
No
How Much/Day?
s Please list any medications, including over the counter, and herbal supplements you are currently taking: trNone
you ever had an allergic reaction to any of the following? fl6se cheekthosethat apply: trNo
trAspirin trCodeine trPenicillin trClindamycin trCipro UDenialAnesthetics CILatex
Fliave
Have you ever had any of the following? Pleasecheckthosethatapply: trNo known conditions
Il Jaundice
tr Heart Attack
tr Allergies:
tr Kidney Problems
tr Heart Surgery
trMigraines
El Seizures
tl Pacemaker
trHead lnjuries
I1 Epilepsy
tr High Blood Pressure
tr Anemia
tr Fainting Spells
fl Low Blood Pressure
t3 Blding Disorder
NADD/ADHD
Il Thyroid Disorder
cl shke
n Blood Thinner
trMental Disorders
tr Back Problems
tr Diabetes Typel rype2
IJ Hay fever
E Cancer
tr Sinus problems
trAlcoholAbuse
tlArthritis
tr Radiation/Chemo
tr Asthma
U Artificial Joints
trRecreational Drug Use
tl Growths/ Turnors
D Emphysema
tr
Bisphosphonate
Use
tr Ulcers
trSTD
EI Tuberculosis
tl Acid Reflux
tr Respiratory problems
BMultiple Sclerosis
nHV/A|DS
tr Stomach Problems
tr Heart MurmurlMVP
B Rhzumaticfever
11
tr
Congenital Heart Defect
Artificial Heart Valves
tr Colitis
E Liver Disease
tr
Hepatitis nA nB qC
tlFibromyalgia
DGlaucoma
Female Patienb Only:
Are you pregnant? aYes r:No
Are you nursing? uYes uNo
To the best of my knowledge, all of the preceding answers and information provided are true and correct. lf I ever have
any change in my healih, I will inform the doctors at the next appointment without fail.
Signature of patient, parent or guardian
l
Referral lnformation
patient-Name:
"
EFamirv';Frien*Name:"?
llHi^:*iJ,'##fl,8i*#*t?:itt-ryil?man**ERncnher
li
ll
il
Patient lnformation
Patient Name:
Date:
Last
ParenUGuardian (if under
First
18):1st
Sex: E Male El Female
Social Security #:
MI
2no
Status:E Manied tr Single tr Child E Divorced
Date of Birth:
tl
Separated E Widowed E Partner
_(Cell):
Phone (Home):
(Work):
Ext:
Preferred Telephone: E Home E Work tr Cell
Email
May we email/text you appointment reminders/changes? tr Yes
Address:
tr No
Apartment #
Street
Zip Code
Employer:
Emergency
Occupation
The following is
Person Responsible For This Account
for: tr Patient (skip this section)
D Policy Holder (compldethis section) tr Other (Completethis section)
Name:
Relation:
Ext:_ (Cell):_
(Work):
Phone (Home):
Address:
(lf different from patient's)
Zp Code
Stale
City
lnsurance lnformatioh
Dsetf Pay/no insuranee
Primary
Patient's
Name of lnsured:
Relation_
Lasl
lnsured's Birth Daie:
tD #:
lnsured's
il
llPharmacy:
lnsured's $ocial Securi$ #:
Group #:
Name:
(wrrereyoumostoftengetPrescriptionsfilled)
Phone:(
Location:-
Pharmacy lnfOrmatiOh
Consent for Services
fnancial rsponsibility on the part of each patist must be ddemined befse treatmst.
All emergencl dental seNi6es, or any dental services performed without prelious financial anangmmts, must be paid
f6
in 68sh at the time Services are perfomed.
for th€ total treatm ent fee.
I
undeFtand that the fee estimate listed forlhis dental care can only be e{ended for a period of 1 year ftom the date ofthe patient s€mination.
all cools and reasonable attomey tees ifsuit be insiituted herglnder.
I
grant my pemission to you or your assignee, lo telephone me at home or at my
wo*
to discuss mallers related to this
fm.
I have read the above conditions of treatrnent and payment and agree to their content.
Date:
Signature of patient, parent or guardian
_
Relationship to Patient:
ll
ll
Written Financial Policy with Shiland Dentistry
Thank you for choosing Shiland Dentistry. Our primary mission is to deliver the best and most comprehensive dental
care available. An important part of the mission is making the cost of optimal care as easy and manageable for our
patients as possible by offering several papent options.
Payment Options:
.
.
r
.
.
Cash, Check, Visa, Master Card, or Discover
7o/o courtesy fee reduction to patients who pay for their treatment of $500 or more in full with cash
PRIOR to the beginning of trmtment (cannot be combined with other discounts including'in-network'fees).
We offer a 7Yo senior citizens discount for our patients ages 65 and older (cannot be combined with other
discounts indudgrs
i
We offer office payment plans for treatment plans of $500 or more with monthly payments over no more
than 6 months. Payment plans must be made PRIOR to treahdnt {late charge fee apply}.
Care
,
We affer a
'in-network'fees).
Credit
i
Dental lnsurance:
r
.
r
.
We are contracted with many insurance companies. Prior to your visit, please verify with your insurance
company that we are a mernber of their network.
Please remernber that your dental insurance is YOUR responsibility. Regardless of what we might calculate
as your dental benefit in dollars, we must stress the fact that you, the patient, is rmponsible for the total
treatnent fee. As you know, not all services are covered by insurance plans, so you should check in
advance to determine if your services will be covered.
For patients with dental insurance we are happy to work with your canier to maximize your benefit and
directly bill thern for reimbursernent for your treatment. However, if we do not receive payment from your
insurance carrier within 60 days, you will be responsible for payment of your treabnent fees and collection of
your benefits direcfly from your insurance canier. We reserve the right to charge a finance charge on any
balance remaining on your account after 60 days.
Since we do file with your insurance company, it will be necessary for us to veriff your insurance prior to
your visit. lf we are unable to ved{y your insurance prior to your appointment, it will be necessary for us to
collect payment in full at time of service.
'Please Note:
.
.
.
.
r
I
.
.
As a condition of your tretment by this office, financial anangements must be made in advance.
Quoted fees can only be extended for a period of 1 year from the date the dentist determines the need for a
specifi c treatment during patient examination.
Shiland Dentistry requires payment of estimatd patient portion of service at checkin, unless previously
written financial arrangements are satisfied. lf you choose to discontinue care before treatment is complete,
you will receive a refund less the cost of care received.
A down payment of 25o/o of patient estimated portion of service must be received to activate payment plans.
Non-established emergency patients must pay balance in full with cash or credit card prior to tretment.
Any fees resulting ftom the collection of your debt is your responsibility.
Appointments cancelled less than 24 hours prior to appointment are subject to a $50 charge fee.
Shiland Dentistry clrarges $25 for returned chmks.
lf you have any questions, please do not hesitate to ask. We are here to hdp you get the dentistry you need.
By my signature, I indicate that I have read this policy, understand its content and agree to its provisions, I agree to
make in-full prompt payment to Shiland Dentistry when billed for any and all charges not covered or paid by vatid
insurance benefits for and in consideration of services rendered. I also understand that I am responsible for any fees
regarding the collection of money due as well aqany finance charges and fees added to the account.
Patient, Pareht or Guardian Signature
Date
lyldXlqpeostine"DD$
2460 lndia Elook Rd., Ste. 207 . Rock
llill, SC 29i132
8ffi€48€00{ . www.$hilandDentisry.com
Sbilardllerttsty
NOTICE OF PRIVACY PRACTICES
This notice describes how healtl informatioa about you may be trsed
and dlrclosed and how you can get access to dris information
Hclgrse reqirlls
OURLEGALDUTY
X rgr.efgffI^ The y*wss sf your hd*h h{wmgEian is int otte*
e
us.
*e
your lreaki informtioo. Ife arc also required to^givc yor *is Notice about our
ars t€qufud by ryplicablc ftdcral and
law to maintain tle priwca of
prir€cy piaetic€s,
t*atadi.., and vourrlghrs'-ii."*iogy*r.heal& iofonudcr-Senuetfotbw&eprirrrlpractices*rataieAqrul inthisNotice while
"to
it b bef€cLThisNoticetoleseffectJ-J
, and eillremain in efect:rntilnereplace lt
lfe
We reserve *re righr n ctrangs our privaca pracrices and dre erms of dris Nodce ar any dme" provided sueh clranges are permitrcd by appticable law. ILre resewe
tle righr to make rhe chan6'es in our Jnirmcy practices and dre nell terms of om Notice effectirrc for all heldr information that we maintain, including health
inftrrmation wecreatexlorreceived bdorercemade dre changes. Before wemakeasigrriftcantchange in ourgrivacy prar*ices, wewill change thit Nrxiceandmake
the new Notie available upon requesl
You
mayrquesta copyofcurNoticeatanytiure For moe inftrmadsn aboutorpirncypractices, orforadditionalcopiesof *isNotice, pleaseccntact
dre information lisaed atdre end of
us
uing
fiisNotice-
AIiID DISCLOSIISES OF HEATTH INFORIUAION
Iile lse and disclose hcalth information about you for eatmmq peymenq and lrealthcare rperations. For erample:
USES
TREJSMENS We may useordisclrrse yourheafuh informatitrr Bra phnrician orodrrheal*rcareproviderprovidingrealrent B)yotr.
PrlYMEll'tr \Ve mey
use and disclose your
halth
information to obtain gaymmt for services we provide to you.
include
HEAIIIICI|3BOFERIIilIOITIS:Wernayuseanddidoseyorrheakhinformatkn incmnectionrvithourheakhcarcqerations'Heal&care operations
comFrenceorqualiFcationsofbsakhcareprohssionals,
*uo..,.-,*.1agi"g training progre{ss,accrcdigtion, ccrtification, liccosiqgorcrdcoti'aling activitics-
;ii'ry.rr*frgJi-p;**"nr*tivideqEvi€rtriDgrhe
eraluatingpra,ctitlonerand providerperfor-
gi:e w wrinen autlroIn addirion to our uce of your hcalth infosaation for trcaffrc$r, Ixrylncrrt, or healthcare opcratioos, you rnay
to anyone for any prxpos. If you give us an autlrorization, you may revoke ir in qriting at any tima Your
in effecs Unless }'ou give us a ntritten aurhorization' ile cannot ssc or
revncadon will nor affec[ any use or discloarres permined by your audroriacion while ic was
in
tfiisNotice.
thosedescribed
e.celrt
reason
f<rratry
dialo*e yourhealth infcrratim
I.ouR ALIEIIORE t'IION:
;d"" ;
,r* 1r"r health information or to disclose ir
ao described in the Patient Righs stion of thisNoticc- !0e may
to help widr your healthcarc or with paymert for your healshncewry
*re
€xreil
to
6iend
or
odrer
member,
family
a
information
to
trsson
dicclo'e your healh
TO yOURlAl,lILy AIrID mIENDS!Ve mrstdiscle yornhealth information oyou,
care, but only
ifyou
agree
*rat ve may do so.
PEnSONS INVOLVSD
IN CAR& Wc may use or disctoac hcetth inforautlon
ro notifr, or asist
in drc notification of (includtg idcnrify&U or locaring) a
your locatiory yourgeneral condition, ordea6- Ifyou'are present, then
Fasdb member, vour per*onal representativeor anofierperson resTonsiblefu-ryour care, of
'an
ro ob;ecr to such uses or disclosures' In the event of your incapacity
you
opportrmity
provide
with
will
we
ioformatioru
vo* t
f"*A on a detemrination using our profrssionnl iudgmenr disclosiog only heakh infonnari<n
or emergency circrmr*ances, we will disclgse healdr
;;;;
;;i*6**
*
of6
*nt
i"fo*".i*
profesrional iudgmenr and our orperierrce widt comn::l p1a:ri""-*
is dincJy reierranc rn dre person's involrremgrr in l,our healthcate. We will also use or
"t"1"
MABIGTII.IG
IilAIXH-nFl|{fJl}
REgU1g5pBYLASI: ltle
SERYICES: We.will not
J*
your heald', irrformati,on for rnarkedng communications without your wrinen au*rori:arion-
may useordisclose yourhealdrinforrnationstrenwe areregui:ed todoso byhw-
you arc a poesiblc victim of abfi'sc
ABUSE OR NEGLESS Wc uray disclosc yorr hcaldr informarion ro apgropriab audF.itic$ if wc rcasonabb bclicvc that
to averl a siqrs dueat ro
exrent
reessr9
your
rhe
idornation
to
hea&h
,*gt*t, oi a"**i. iiolence q &e posible vicrin of oder crirc. lfe rnay dirclooe
of
odlers
orsafety
youheakh otsfety or the health
ffi
M"L
l{Iotrc*stinci DD$
.
2460 India l{ook 8d-, Ste, 2O? Rock Hill , SC 29732
803€48€004
SbiladDentistry
.
www.ShilandDentirsFy.com
may discl€se !o Rilitary arfurities tie heatrtr informatioa of Armed Forces pg{sonnel under cerain cimrmstances- We may
authorized hderal officials healtt iofrrnadon reryird for lexrful intefiigBnce couaeriatelligence, and odrer oational secutity activities. We may
h having lasfixl crrrcdyofproeed healdr infarcradon of inmaesorpatierrtsundercerrain circumirstinrdonq
NAilIONAL SEAURITY! V'e
di*lose
o
la*
ffimconectlonat
APPOINTMENT REMINIXRS: We may
postcancls,
use
or disclose your health information to provide you with appoinrment reminders tsuctr as voicernail messagea
or letrers).
PAIIENTRIGIITS
Access: Yorr bt'e tteright to look atorget
copies of yourhealth
inbrmtion, with limited excqrtions.You
may request that we prcvide copies in a
formato&cr
V/esill use6efrrmatyou relrx*t.rnlessne cmrot pra$habbdo p. (Ycmmnst'nakc a re$res inMiting b obainecess o yorn heakh
inbrmerion You may obtaia a 6rm !o reqrcst access \- usirqg the contact idotffiti@ lised ag dre end of this Notice We wiil chage ydr a reasomble cost based
rhanphorocopies
fee fur erpenses
srch
as
urpies end saff dme Yor may alm rcquest acces by surding us a le*er sr drc address at the end of dris Nodce. If ycm req*sr cnpia'
se
*illdrargeyu$0. foreachp"ge$ perhorrforsnafftirneocopryynnheal& infarmation,andyxageifyourtantthecopi€smailed toyou- Ifyou reguest
**tt r*ti"A*r".,or"willchargeacofi.bescdfeeforpmxi&ngyouthealdriofumrationindrarfofira:.Ifyouprder,uewillpreprganrmmaryttranexplalarion ofyour healdr infornation for a Ge. Conracr
us
using the infomratioo
listd
at the end of
thil Notice fs a full erplanadon of
our fee stnrchne.)
DISCLOSU11E ACCOIINIING: You have t}e rigirt to rseive a lisr of irutances in rvhich rse or our business associates disclosed your healdr iaformation for
purpoes o*rer than treatneor, F yment, hcakhcare o'peratior$, add c€rcain o&cr activitie.s, for.th€ last 6 years, but not before A*-il 14' 2003- If you requet rhis
noi *.iog *o* than once in a li-monrh p.riod, we may dharge you a reacooable, cost-based fee for reponding to dtese additional rcqu€sts.
RESTRICIIONi
You har.e
&e rigk
o
request
agee to *rese additioml rsrrictiom, hrt if tle
AIIERNAIWE COR{MUI{ICATION:
tlat
&,
YaL
we
lnre
we place additional rcstricrions oo our rse or disclozute of your health infonrmticn-
Ve
are aot
rcqriled to
will abide by our agreeoent {except io an emergency
dre righr El reqresr
dar{a
communicare wirh you about ya,tr health infrrrmtion hy 'alteuradre mtans or ttt
how paymens will be handlcd undq the akemative means or location you fequesL
(Your request mu$ be in writing, and
have thc right to rcquest that we amend your heal*r informatisrshoulil be ameoded-) Y/e may deny your request under ceftain circumstalrces
AMENDMEI\IE you
ELESTRSNIC NO1ICT$ If
it must explain rvhy ihe inbrmation
you rcccivc this Noticc on our w&sirc or by clcctronic mail (c-rnail) , ),ou arc cndrlcd to rcccivc this
Notkc in ryritrcn forar'
QUESTIOI{S AND COMPIAINTS
iifior l*dnt
more
inforrntisr
about nrnptirracy pre3tices orhaveguexionsorconcerns, pl€ase aqnactns.
infixmation or in rcspon$e
Ifyou are concemed thatwe may haveviolaredyonprivacytights, oryou disageqithadecisionrremadeaboutaeestgwr-hat*r
means otat alterna'
altemative
by
with
have
uscommunicate
orro
ilfornaaon
1ou
to a.eqilesryou mud" to*r.*..d orrestrict dre use *ii""iJrr"Fyo-ieald,
to trrc^u's-DwarE'
You
maysrbmitawrinen
abg
gngliJr3
at&eendof
thisNotiqe.
i$forsrari@lised
conac
to
ususingdre
tirrclocations, pu nnrycomp*n
HurnanServicesupon
DeparmentofHealiand
*e
US.
W.o=iltpro"ia.ynr *i& &c addasscoffleyorrcomplaintwirh
is"*r*"
;;;;;A'*Jil
request
We$pportyour rigfuto dreprivacyofrqrheaki infonmtion. wewill notreraliate inanT
raent of Healdr frtd
nray
ifyouchoose tofilea comsa:*withusorntidr
dreUS'hputt-
Humn Servi6-
ShihodDelrtistrY
hd-" IilL na-,
ics
s..
zoz
Rock Hill, SC 29?32
TeL
803J2&ES4
f
OiCS!,409Aqto DocdAcc;"to.in&ht:tffiEd.
Rrr.&sicaadeofdsftr&trd'6l'6drtr:hs&br1646nccblrlce?.dtc{.rcarodcc.d4illdmrdl*{rdoofd*fotray<dr?dEEge6*EFit$trtl?clnf*'Ascao
?hlr&ra&dsr-d oerlr,Jcn*<astrehprldvlceadoreorlGdal rrorals(Adgf 14':ED'
DmdAeocdqr
Mar &t1{o pensfine, C, 0, S,
Acknowledgement of Receipt of
* Notice of Privacy fractice
You May Refuse to Sign This Acknowlpdgement.
Privacy Practices
(HIPAA) ,
'i.
We use the contact information that you provide for appointment reminders and to contact you regarding your
appointments and care. By signing below, l,
acknovdedge that I have read and understand Shiland Dentistry's Notice of Privacy Practices, which is posted on the
Shiland Dentistry's website and is also available at the check-in desk. I also have been given the opportunity to receive a
copy.
mail: trYes n No
via email: tr Yes tr No
via text message: tr Yes tl
a
I authorize communication via voice
a
I authorize communication
a
I authorize communication
No
Please list any persons to whom your protected health information can be disclosed (e.9., spouse, parent, etc.):
Name:
Phone #(s):
Relationship:
Name:
Phone #(s):
Relationship:
By signing below, I authorize the release of medical information to my primary care and/or refening physician, to medical
consultants if needed, and as nec,essry to process insurance claims, insurance applications, and prescriptions.
Date:_
Relationship to patient:
Signature of patient, parent or guardian
*For
Office Use
Only*
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be
obiained b*ause:
lndividual refused to sign
Communication baniers prohibited obtaining the acknowledgement
An enrerggncy situation prevented us from'obtaining acknowledgement
Other (Please speify):
Prepared by:
aga
hnd;a
Signature:
?too|fuad'
Suife
z0/ ' fut[.]+{f ' EC' zg73z'
P6one
8ry428-8004'
ww*,srti{anfdenfistry.com