New Patient Forms - Advanced Dentistry

Date:
REGISTRATION FORM
Thank you for expressing your confidence in choosing our practice! We look forward to assisting you with your dental needs. Please fill out this form in ink
only. If you have any questions regarding this form do not hesitate to ask for assistance. We will be happy to help.
Patient Name: ________________________________________________ Birth Date:
First
Last
SS#:_____________________________ DL#:____________________
Sex: Male
Marital Status:
Single
Married
Divorced
Widowed
Partnered
Spouse/Guardian Name:
Text Message 1 day before appts?
Home Address: ______________________________________City/State/Zip:
Home Phone: ______________________ Cell: ______________________ Work:
Email Address:
What is the best way to contact you?
Home
Cell
Email
Work
Employer Name: _____________________________________ Occupation:
Address: ____________________________________ City/State/Zip:
Female
Yes
No
Whom may we thank for referring you?
RESPONSIBLE PARTY
Name of person responsible for account: ___________________________________ Relationship:
DOB: ______________ Age: _______ SS#:_______________________ Phone:
Address: _______________________________________ City/State/Zip:
Employer Name: __________________________________ Work Phone:
*Please list an Emergency Contact not living with you. Name:
Phone:
Relationship:
PRIMARY DENTAL INSURANCE INFORMATION
Subscriber’s Name: _______________________________________ Relationship:
DOB: _____________ SS#:__________________________ ID#:
Insurance Company: _______________________________________Group #:
Ins Phone#:_________________________ Ins Address:
Employer’s Name: _________________________________ Work Phone:
Do you have Secondary Dental Insurance?
YES
NO
Subscriber’s Name: _______________________________________ Relationship:
DOB: _____________ SS#:__________________________ ID#:
Insurance Company: _______________________________________Group #:
Ins Phone#:_________________________ Ins Address:
Employer’s Name: _________________________________ Work Phone:
I hereby authorize payment directly to the dental office of the group insurance benefits otherwise payable to me. I understand that I am responsible
for all costs of dental treatment. I hereby authorize the dental office to administer such medications and perform such diagnostic, photographic and
therapeutic procedures as may be necessary for proper dental care. The information on this page and the dental/medical histories are correct to
the best of my knowledge. I grant the right to the dentist to release my dental/medical histories and other information about my dental treatment to
third party payers and/or other health care professionals as is beneficial for payment or dental care.
Signature of Patient or Parent/Guardian
Date
MEDICAL HISTORY
Date: ____________________
Patient Name: _______________________________________________________
DOB: _____________________
Check () if you have or have had problems with any of the following:
AIDS/HIV Positive
Yes
No
Diabetes
Yes
No
Neurological Problems
Yes
Allergies
Yes
No
Emphysema
Yes
No
Pacemaker
Yes
No
Anemia
Yes
No
Endocarditis
Yes
No
Psychiatric Care
Yes
No
Angina
Yes
No
Epilepsy
Yes
No
Radiation Treatment
Yes
No
Anxiety
Yes
No
Fainting or dizziness
Yes
No
Respiratory Disease
Yes
No
No
No
Arthritis, Rheumatism
Yes
No
Fibromyalgia
Yes
No
Rheumatic Fever
Yes
Artifical Heart Valves
Yes
No
Glaucoma
Yes
No
Scarlet Fever
Yes
No
Artifical Joints
Yes
No
Headaches
Yes
No
Shortness of Breath
Yes
No
Asthma or Hay Fever
Yes
No
Heart Attack
Yes
No
Seizures
Yes
No
Back Problems
Yes
No
Heart Murmur
Yes
No
Sinus Trouble
Yes
No
Bleeding abnormally, with
Yes
No
Heart Disease
Yes
No
Skin Rash
Yes
No
extractions or surgery
Yes
No
Hemophilia
Yes
No
Special Diet
Yes
No
Blood Disease
Yes
No
Hepatitis Type ______
Yes
No
Stroke
Yes
No
Blood Transfusion
Yes
No
Herpes
Yes
No
Swollen Feet or Ankles
Yes
No
Cancer Therapy
Yes
No
High Blood Pressure
Yes
No
Swollen Neck Glands
Yes
No
No
Chemical Dependency
Yes
No
Jaundice
Yes
No
Thyroid Problems
Yes
Chemotherapy
Yes
No
Jaw Pain
Yes
No
Tonsillitis
Yes
No
Circulatory Problems
Yes
No
Kidney Disease
Yes
No
Tuberculosis
Yes
No
Claustrophobia
Yes
No
Leukemia
Yes
No
Tumor or growth on
Yes
No
Congenital Heart Lesions
Yes
No
Liver Disease
Yes
No
head or neck
Yes
No
Contact Lenses
Yes
No
Low Blood Pressure
Yes
No
Ulcer
Yes
No
COPD
Yes
No
Measles or mumps
Yes
No
Venereal Disease
Yes
No
Weight Loss, unexplained
Yes
No
Yes
No
Cortisone Treatments
Yes
No
Mitral Valve Prolapse
Yes
No
Cough, persistent or bloody
Yes
No
Nasal Obstruction
Yes
No
Medications routinely used in dental treatment may interact with both prescription and a number of illegal street drugs. Check () the
medications you are presently taking, medications you have taken in the past, or medications you have had an adverse reaction to:
Presently Taken in History of
Taking the Past Reaction
Presently Taken in History of
Taking the Past Reaction
Cortisone or Other Steroids
Coumadin, Heparin, Warfarin
or other blood thinners
Dilantin
Diuretics (water pills)
Fen-phen (Lonimin, Adipex, Fastin,
Phentermine, Pondimin, Fenfluramine,
Redux, Dexfenfluramine)
Heart Medications such as Digoxin,
Nitroglycerin or Digitalis
Ibuprofen (Motrin)
Anesthetics, Locally Injected
Anesthetics, General
Antacids
Anti-anxiety Medications
Anti-depressants
Antihistamines
Daily Aspirin Regimen
Birth Control Pills
Blood Pressure Medications
Codeine, Demerol or
Other Analgesics
Presently Taken in History of
Taking the Past Reaction
Insulin or Diabetes Medications
Sedatives or Tranquilizers
Sleeping Pills (Barbiturates)
Thyroid Medication such as Synthroid,
Levoxyl or Levothyroxine
Tylenol (Acetominophen)
Adverse reaction to any other
medication or drug
Yes
No
Please specify ______________________________
___________________________________________
___________________________________________
List the other medications you are curretnly taking and what condition you are taking them form Include vitamins,
supplements, herbs and over the counter medications.
Medication
Condition
Check () your current use of:
Prescribing Doctor
Tobacco
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Packs per day ________
Alcohol, Beer, Wine
Pharmacy Name
Drinks per day ________
Phone
Women: Are you pregnant?
Yes
Have you had any serious illnesses or surgeries?
No
Nursing?
Yes
If yes, describe
Yes
No
No
Street Drugs
Times per day ________
Caffeine
Cups per day _________
Do you have any other health needs you should bring to our attention?
High Stress
Reason _____________
To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.
Signature of Patient, Parent, Guardian or Personal Representative
Date
Please print name of Patient, Parent, Guardian or Personal Represtative
Relationship to Patient
DENTAL HISTORY
Date:
Patient Name:
DOB:
Dental Clinic:
Dentist's Name:
Street Address:
City/St/Zip:
Phone:
Date of Last Appt:
Date of Last X-Rays:
Why did you leave your previous dentist?
Check () if you have or have had problems with any of the following:
Bad Breath
Yes
No
Chew on one side of mouth
Yes
No
Bleeding gums
Yes
No
Tobacco use
Yes
No
Gums swollen or tender
Yes
No
Chewing on foreign objects
Yes
No
Sores, blisters, growths on lips or mouth
Yes
No
Fingernail biting
Yes
No
Burning sensation on tongue
Yes
No
Thumb sucking
Yes
No
Biting cheeks or lips
Yes
No
Tongue thrusting
Yes
No
Dry mouth
Yes
No
Pain on brushing teeth
Yes
No
Mouth breathing
Yes
No
Loose or broken teeth
Yes
No
Chewing
Yes
No
Loose or broken fillings
Yes
No
Swallowing
Yes
No
Food collection between the teeth
Yes
No
Talking
Yes
No
Sensitivity to cold
Yes
No
Prominent gag reflex
Yes
No
Sensitivity to hot
Yes
No
Snoring
Yes
No
Sensitivity to sweets
Yes
No
Periodontal treatment
Yes
No
Sensitivity when biting
Yes
No
Pyorrhea or trench mouth
Yes
No
Stained teeh
Yes
No
Orthodontic Treatment
Yes
No
Grinding or clenching teeth
Yes
No
Wisdom teeth extracted
Yes
No
Clicking or popping jaw
Yes
No
Bite problems
Yes
No
Jaw pain or fatigue
Yes
No
Missing teeth
Yes
No
Opening or closing jaw
Yes
No
Shifting position of teeth
Yes
No
Pain around ear
Yes
No
How often do you brush?
How often do you floss?
How often do you have your teeth cleaned?
How often do you change toothbrushes?
PATIENT GOALS
What is your goal for dental treatment today?
Are you in discomfort today?
Yes
No
Are you pleased with the appearance of your teeth?
Do you like your smile?
Yes
No
Does dental treatment make you nervous?
Yes
If no, please explain:
No
If no, please explain:
Yes
Have you been pleased with your previous dental care?
If yes, please explain:
No
Yes
No
Have you ever had a bad experience in a dental office? If so, please explain:
How can we help improve your teeth and smile?
Signature of Patient
Date
Patient Agreement
We would like to take this opportunity to welcome you to Advanced Dentistry. The following is
an agreement between Advanced Dentistry and you (or the individual taking responsibility for
payment if someone other than you). By executing this agreement, you are agreeing to pay for
all services received.
Treatment Plans
During your appointment at Advanced Dentistry you will be given a treatment plan estimate that
will give you a financial guideline to your treatment. Although we make every effort to minimize
changes to your treatment plan, changes may arise after treatment is initiated. As this occurs, a
new treatment plan will be written and presented to you. Please know that treatment plans do
not represent additional appointments that cannot be foreseen, such as emergency
appointments, denture relines, temporary crown replacements, etc. These additional
appointments are billed on a “per appointment” basis, depending on procedure. We DO NOT list
them on your treatment plan, as not all patients may need them.
Appointments
Please know that Advanced Dentistry generally schedules around 2-4 weeks in advance for
appointments, unless you are a patient of record experiencing a dental emergency. Therefore,
we ask that you provide appropriate notice before cancelling or rescheduling an appointment so
that we may offer the time to another patient seeking dental care. Advanced Dentistry requires 2
days’ notice to be given during regular office hours (8:00am-5:00pm) to avoid a $60 per half
hour charge. Messages left on the machine overnight less than 2 days prior to an appointment
are not accepted as proper notice. Advanced Dentistry will not schedule patients that have
missed or cancelled two appointments without proper notice.
Insurance
As a service to you, we will do our best to help you receive the maximum benefits available
under your private or employer purchased policy. Please be aware that most insurance
companies will not cover all dental costs, but may pay a fixed allowance for certain procedures.
As a courtesy, we will send all dental claims to your insurance company at your request,
but we require payment on all services to be paid up front regardless of insurance
coverage. Any over payment made by your insurance will be sent either to you directly by your
insurance company or issued as a refund by Advanced Dentistry. Although we may estimate
what your insurance company may pay, it is the insurance company that makes the final
determination of your eligibility and insurance benefits. We are happy to assist you with any
further insurance needs you may have.
Payment Terms
We accept cash, checks, Visa, Master Card, Discover and American Express. We do not do any
in office financing, however we do work with both CareCredit™ and Lending Club Patient
Financing. For more information, please contact our office. There will be a charge of $35 for all
returned checks and all future payments will require cash or credit card payment.
All fees for dental services are due when rendered.
Overdue Accounts/Finance Charges
Advanced Dentistry makes every effort to ensure that all accounts are paid at the time services
are rendered. If prior payment arrangements are made, payments are due in accordance with
that agreement. Should a payment become 30 days past due, a late fee will be assessed at $35
per month, occurring on the 1st of the month. If no payment arrangements have been made the
entire balance is due within 25 days of the received statement, according to Oregon law. The
same late fees and timelines apply. After 90 days of non-payment on an account, the account
may be sent to collections with a final rebill fee of $35. Prior to this, all necessary steps will be
taken to collect on any overdue account, in accordance with the collection laws of Oregon.
In an effort to keep our costs at a reasonable rate we do not have an in-house collections
department. Due to that fact, we contract with an agency. If we have to refer your account to a
collection agency, you agree to pay any and all costs in association with that agency. You also
agree to assume all costs incurred for court and lawyer fees, should the account move to
litigation. Litigation may also require that any treatment you received in our office may become
a matter of public record.
Transferring of Records
Records requests other than the transfer of x-rays to another provider will need to be in writing.
In cases where your records exceed 10 pages, require color copies, and/or are delivered by a
delivery service, a reasonable fee may be applied. Any costs incurred by Advanced Dentistry to
forward these documents to you, another doctor, or organization will be forwarded on to you and
will need to be paid prior to the release of your records. If you are having records transferred
from another facility to ours, you authorize us to receive all relevant information on your behalf.
Assignment and Release
For those individuals with insurance, your signature below hereby authorizes your insurance
benefits to be paid directly to Advanced Dentistry. It also authorizes the doctor to release any
information required for payment and processing of this claim. Please sign below to
acknowledge your understanding of the information contained herein.
________________________________________
Printed Name
_______________________________________________ _
Signature
_______________________
Date
Effective Date: Your signature on this agreement indicates you agree to all of the terms and conditions contained in
the agreement. The agreement is effective as of the date signed and dated above
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES NOTICE
Include This Acknowledgement In the Patient’s Records
Please sign and date below to indicate that you have received a copy of our Privacy Policy notice.
Your signature simply acknowledges that you received a copy of this notice.
Print Name:
Signature:
Date:
Patient’s Authorized Representative
If patient is under 18 years of age, or you are consenting to the care of another
If a personal representative signs this authorization on behalf of the individual, the representative
states that he/she has the legal authority to sign this acknowledgement on behalf of the following
patient:
Patient’s Printed Name:
Personal Representative’s Printed Name:
Relationship to Individual:
Personal Representative’s Signature:
Date:
Good Faith Effort to Obtain Acknowledgement of Receipt
If patient or patient’s representative refuses to acknowledge receipt
Describe the reason why the individual would not sign this form:
NOTICE OF PRIVACY PRACTICES
As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
THIS NOTICE DESCRIBES HOW CERTAIN HEALTH INFORMATION ABOUT YOU, AS A PATIENT OF THIS
PRACTICE, MAY BE USED, DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
In conducting our business, the doctors and staff of Advanced Dentistry creates records regarding you and the treatment and
services that we provide to you. We are committed to abide by all applicable laws regarding the protection of your individually
identifiable health information (“health information”). This notice is intended to provide information to you about our privacy practices,
our legal duties, and your rights concerning your health information.
This notice is effective as of August 11, 2007 (the “Effective Date”) and its scope applies to all records containing your health
information that are retained or created by us after the Effective Date. We reserve the right to change our privacy practices and the terms
of this notice at any time, and such new privacy practices will be effective for any records that we have created or maintained in the past
or that we may create or maintain in the future. Before we make any material changes in our privacy practices, however, we will make
our new notice available upon request.
OUR USES AND DISCLOSURES OF HEALTH INFORMATION
For Treatment: We may use your health information to provide you with dental treatment and related services. We may disclose your health
information to other dental offices, dentists, physician offices, laboratories, providers, agencies, facilities, pharmacies, transport companies,
family members, or other health care providers and their staff involved in providing health related treatment, services or care to you. For
example, we may disclose your health information to a pharmacy to write a prescription for you. We may communicate with you about or
recommend possible treatment options or alternatives that may be of interest to you. We may use or disclose your health information to provide
you with appointment reminders (such as voicemail messages, postcards, or letters) or informational, educational purposes or promotional
materials such as practice newsletters.
For Payment: We may use and disclose your health information (e.g., x-rays, billing statements, etc.) to persons or entities (e.g., insurance
companies, family members, third party payers, health plans) so that you (or we as the case may be) can be reimbursed for treatment and
services we provide to you.
For Health Care Operations: We may use and disclose your health information for our health care operations. Health care operations include
quality assessment and improvement activities, reviewing the competence of health care professionals, evaluating practitioner and provider
performance, conducting educational or training programs, accreditation, certification, licensing or credentialing activities or to detect or
prevent health care fraud and abuse, contractual obligations, patients’ claims, grievances or lawsuits, health care contracting, legal, tax, or
business planning and development, business management and administration, promotional programs, the sale of all or part of Advanced Dentistry
to another entity, underwriting, claims management and other insurance activities. We may disclose your health
information to another health care provider or organization to support some of their health care operations.
Relatives, Caregivers and Personal Representatives: We may disclose your health information to a family member, friend, personal
representative, or other person you identify that is involved in your dental or health care or with payment for your dental or health care. Unless
you have otherwise provided us the authorization to do so, before we disclose your health information to such people, we will provide you with
an opportunity to object to our use or disclosure. If you are not present, or in the even of your incapacity or an emergency, we will disclose
your medical information based on our professional judgment of whether the disclosure would be in your best interest. We may use our
professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to
pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information. We may use or disclose information about
you to notify or assist in notifying a person involved in your care, of your location and general condition.
Health Related Benefits and Services: We may contact you about benefits or services that we provide.
Disaster Relief Efforts: We may use or disclose your health information to a public or private entity authorized by law or by its charter to
assist in disaster relief efforts.
News Gathering Activities: We may contact you or one of your family members to discuss whether or not you want to participate in a media
or news story (e.g., a news reporter working on a story about dental health may ask whether any patients undergoing some sort of specific
dental treatment may be willing to interviewed).
Public Benefit: We may use or disclose your medical information as authorized by law for the following purposes deemed to be in the public
interest or benefit, including without limitation, for public health activities, including disease and vital statistic reporting, child abuse reporting,
FDA oversight, and to employers regarding work-related illness or injury; to report adult abuse, neglect, or domestic violence; to health
oversight agencies; to coroners, medical examiners, and funeral directors; to an organ procurement organizations; to avert a serious threat to
health or safety; in connection with certain research activities; and to the military and to federal officials for lawful intelligence,
counterintelligence, and national security activities.
As Authorized or Required By Law: We will disclose health information when authorized or required to do so by applicable law, including
without limitation, in response to court and administrative orders and other lawful processes; to law enforcement officials pursuant to subpoenas
and other lawful processes, concerning crime victims, suspicious deaths, crimes on our premises, reporting crimes in emergencies, and for
purposes of identifying or locating a suspect or other person; to correctional institutions regarding inmates; and as authorized by state workers’
compensation laws.
Lawsuits and Similar Proceedings: In connection with lawsuits or other legal proceedings, we may disclose health information about you in
response to a court or administrative order, or in response to a subpoena, discovery request, warrant, summons, or other lawful process. We
may disclose health information to courts, attorneys, and court employees in the course of litigation, arbitration, or other judicial or
administrative proceedings.
Law Enforcement: If asked to do so by law enforcement, and as authorized or required by law, we may release medical information: to
identify or locate a suspect, fugitive, material witness, or missing person; about a suspected victim of a crime if, under certain limited
circumstances, we are unable to obtain the person’s agreement; about a death suspected to be the result of criminal conduct; about criminal
conduct at Advanced Dentistry; and in case of a medical emergency, to report a crime; the location of the crime or victims; or the
identity, description or location of the person who committed the crime.
Coroners, Medical Examiners and Funeral Directors: In most circumstances, we may disclose medical information to a coroner or medical
examiner. This may be necessary, for example, to identify a deceased person or to determine cause of death. We may also disclose medical
information about patients of Advanced Dentistry to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities: As authorized or required by law, we may disclose medical information about you to
authorized federal officials for intelligence, counterintelligence, and other national security activities.
Other Uses of Health Information: Not every specific use or disclosure of your health information is listed in this notice. Unless you provide
us (or have already provided us) with separate written authorization to use or otherwise disclose certain personal or health information for
certain purposes, all of the ways we are permitted to use and disclose health information will fall within one of the following categories.
PATIENT RIGHTS
Your health information that we have created and maintain is the property of Advanced Dentistry. You have the following rights,
however, regarding your health information that we maintain.
Right to Inspect and Copy: You have the right to look at or get copies of your health information, with certain exceptions. You may make
reasonable requests that we provide copies in a format other than photocopies. We will use the format you request unless it is unduly
burdensome to do so. You must make a request in writing to obtain access to your health information by sending a letter to the Privacy Officer
identified at the bottom of this notice. If you request copies, we will charge you a fee for these services that may include labor, duplication
costs, and postage. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If
you prefer, we may – but are not required to – prepare a summary or an explanation of your health information for a fee. Contact us using the
information listed at the end of this notice for more information about fees.
Right to Amend: You have the right to request that we amend your health information if you believe that the health information that we have
about you is incorrect or incomplete. Your request must be in writing to the Privacy Officer identified at the bottom of this notice, and it must
explain reasons that support your request to amend your health information. We may deny your request under certain circumstances (e.g., it is
not in writing, does not have support for the request, asks that we amend information that is accurate or complete, was not created by Advanced
Dentistry, etc.).
Right to Disclosure Accounting: You have the right to request a list of certain disclosures we have made of your health information. To
request this accounting of disclosures, you must submit your request in writing to the Privacy Officer identified at the bottom of this notice.
That list will not include disclosures for treatment, payment, health care operations, as otherwise authorized by you, and for certain other
activities. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding
to these additional requests. Contact us using the information listed at the end of this notice for more information about fees.
Right to Request Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health
information for treatment, payment or healthcare operations. We are not required to agree to these additional restrictions, but if we do, we will
abide by our agreement (except in an emergency). In your request, you must tell us: (1) what information you want us to limit; (2) whether you
want to limit our use, disclosure or both; and (3) to whom you want the limits to apply. We are not required to agree to your request. If we do
agree, our agreement must be in writing signed by a person authorized to make such agreement on our behalf and we will endeavor to comply
unless the information is needed to provide emergency treatment.
Right to Alternative Communication: You have the right to request that we communicate with you about your health information in a certain
way or at a certain location. You must make your request in writing to Advanced Dentistry at the address listed at the bottom of this
notice. You must specify in your request the alternative means or location, and provide satisfactory explanation how you will handle alternative
payment under the alternative means or location you request. We will endeavor to comply with all reasonable requests.
Right to Copies of This Notice: 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. You may request a paper copy of our notice.
Right to File A Complaint: You may contact Advanced Dentistry if you believe that we have violated your privacy rights, we made
a decision about access to your health information incorrectly, our response to a request you made to amend or restrict the use or disclosure of
your health information was incorrect, or we should communicate with you by alternative means or at alternative locations. You also may
submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint
with the U.S. Department of Health and Human Services upon request. We will not penalize you on the basis of filing a complaint.
CONTACT INFORMATION
If you want more information about our privacy practices or have questions or concerns, please contact us using the information listed below.
Advanced Dentistry
11790 SW Barnes Road, Suite 260
Portland, OR 97225
Phone: 503-352-3224
Private Contract
•
•
•
We, Dr. David Halmos and Dr. Lauren Manning have not been excluded from Medicare under [1128]
§§1128, [1156] 1156 or [1892] 1892 of the Social Security Act.
I the Medicare beneficiary or my legal representative accept full responsibility for payment of charges
for all services furnished by Advanced Dentistry.
I the Medicare beneficiary or my legal representative understand that Medicare limits do not apply to
what Advanced Dentistry may charge for items or services furnished.
•
I the Medicare beneficiary or my legal representative agree not to submit a claim to Medicare or to ask
Advanced Dentistry to submit a claim to Medicare.
•
I the Medicare beneficiary or my legal representative understand that Medicare payment will not be
made for any items or services furnished by Advanced Dentistry that would have otherwise been
covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.
•
I the Medicare beneficiary or my legal representative enter into this contract with the knowledge that I
have the right to obtain Medicare-covered items and services from a physician and/or practitioner who
has not opted-out of Medicare, and that the I am not compelled to enter into private contracts that
apply to other Medicare-covered services furnished by other physicians or practitioners who have not
opted-out.
•
The expected or known effective date and expected or known expiration date of the opt-out period is
5/20/2015 and 5/20/2017.
•
I the Medicare beneficiary or my legal representative understand that Medigap plans do not, and that
other supplemental plans may elect not to, make payments for items and services not paid for by
Medicare.
•
This contract cannot be entered into by myself, the Medicare beneficiary, or by my legal representative
during a time when I, the Medicare beneficiary, require emergency care services or urgent care
services. (However, a physician/practitioner may furnish emergency or urgent care services to a
Medicare beneficiary in accordance with §3044.28 of the Medicare Carriers Manual)
•
I the Medicare beneficiary or my legal representative will receive or have received a copy (a photocopy
is permissible) of this contract, before items or services are furnished to me under the terms of this
contract.
•
We, Dr. David Halmos and Dr. Lauren Manning will retain the original contract (original signatures of
both parties required) for the duration of the opt-out period.
We, Dr. David Halmos and Dr. Lauren Manning will supply CMS with a copy of this contract upon
request.
•
•
We, Dr. David Halmos and Dr. Lauren Manning understand that the current private contract remains in
effect for two years. If I again opt-out of Medicare, I will expediently complete a new contract for each
Medicare beneficiary and will expediently submit the appropriate affidavit(s) to all local Medicare
carriers.
7/8/2015
________________________________________
_______________________
(Provider’s Signature: David R. Halmos)
________________________________________
(Provider’s Signature: Lauren B. Manning, DDS, DMSc)
________________________________________
(Patient’s Signature)
________________________________________
(Patient’s Name)
________________________________________
(Patient’s Legal Representative)
________________________________________
(Witness)
(Date)
7/8/2015
_______________________
(Date)
_______________________
(Date)
_______________________
(Date)
_______________________
(Date)
________________________
(Date)
11790 SW BARNES RD, STE 260
PORTLAND, OR 97225
(503) 352-3224
www.advanceddentistrypdx.com
Directions to the Barnes Road Professional Campus
Our office is located in the Barnes Road Professional Campus in southwest Portland on S.W.
Barnes Road two blocks west of S.W. Cedar Hills Blvd. Please call our office for directions if
you are unfamiliar with the area.
Coming from Portland on Sunset Highway (26): Take Exit 68 (Cedar Hills Blvd) and
turn right onto SW Cedar Hills Blvd. At the first light, turn left onto SW Barnes Rd. Go
approximately 0.3 miles and just past SW 117th/Sunset Medical Clinic. Get into the left turn
lane and turn into the Barnes Road Professional Campus. Our building (11790) is near the
back of the campus in front of the parking structure.
Coming from the South on Highway (217): At the North end of Hwy 217, take the
Barnes Road exit and then stay in the left lane to head West on Barnes Road. Travel on
Barnes Road approximately 0.3 miles past Cedar Hills Blvd and just past SW 117 (Sunset
Medical Clinic).
Get into the left turn lane and turn into the Barnes Road Professional Campus. Our building
(11790) is near the front of the campus in front of the parking structure.
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Coming from the West on Sunset Highway (26): Take Exit 68 (Cedar Hills Blvd).
At the bottom of the ramp turn left on SW Cedar Hills Blvd. At the second light, turn left
onto SW Barnes Road. Go approximately 0.3 miles and just past SW 117th/Sunset Medical
Clinic. Get into the left turn lane and turn into the Barnes Road Professional Campus. Our
building (11790) is near the back of the campus in front of the parking structure.