Welcome to Marietta Smile Gallery / Bienvenido a Marietta Smile Gallery
Patient Information / Información del Paciente First Name / Nombre
Last Name / Apellido
Address / Dirección
City / Ciudad
Home Phone Number / Teléfono particular
State / Estado
Zip / Código postal
Work Phone Number / Teléfono laboral
Cell Phone Number / Teléfono celular
Email / Correo electrónico By providing my email address, I consent to receive emailed appointment reminders and patient communications from Marietta Smile Gallery, LLC. I understand I may unsubscribe at any time. / Al proporcionar mi correo electrónico, doy mi consentimiento para recibir recordatorios de citas por correo electrónico y comunicaciones para pacientes de Marietta Smile Gallery, LLC. Entiendo
que puedo cancelar la suscripción en cualquier momento.
Social Security Number / Número de Seguro Social
Date of Birth / Fecha de nacimiento
Emergency Contact Name / Nombre del contacto de emergencia Phone Number / Teléfono
Policy Holder/Responsible Party Information / Información del Responsable/Titular de Póliza Name (if other than patient name) / Nombre (si no es el paciente)
Relationship to Patient / Relación al Paciente
Address / Dirección
City / Ciudad
State / Estado
Social Security Number / Número de Seguro Social
Policy Holder’s Date of Birth / Fecha de Nacimiento del Titular de Póliza
Zip / Código postal
Employer Name / Nombre del Empleador Insurance Company / Empresa de Seguro Sindicato/Local Group or Policy Number / Número de Póliza o Grupo
Union/Local /
Dental History / Antecedentes Dentales Previous Dentist Name / Nombre del Dentista Anterior
Reason for Leaving / Motivo de Abandono
Date of last cleaning / Fecha de última limpieza
Explain the reason for your visit today / Explique el motivo de la visita de hoy
How did you hear about us? / ¿Cómo se enteró de nosotros? (Page 1 of 4 / Página 1 de 4)
Dental History / Antecedentes Dentales (continuación) o o o o o o o o o o o o o o
Do you take a fluoride supplement? ¿Toma suplemento de flúor?
Y / S Are you experiencing any discomfort? N / N ¿Siente alguna molestia?
o
Y/S
o
N/N
Y / S Do you snore? N / N ¿Usted ronca?
o
Y/S
o
N/N
Y / S Do you have bleeding gums? N / N ¿Le sangran las encías?
o
Y/S
o
N/N
Do you drink coffee or tea? ¿Bebe café o té?
Y / S Do you have bad breath? N / N ¿Tiene mal aliento?
o
Y/S
Interested in having whiter/brighter teeth?
o
N/N
¿Le interesaría tener dientes más blancos/brillantes?
Y / S Do you grind your teeth? N / N ¿Aprieta los dientes?
o
Y/S
Do you have difficulty brushing your teeth?
o
N/N
¿Tiene dificultades para cepillarse los dientes?
Y / S Do you play sports? N / N ¿Practica algún deporte?
o
Y/S
o
Y / S Are you sensitive to hot, cold or sweets? N / N ¿Tiene sensibilidad al calor, el frío o los dulces?
Do you use tobacco (smoke or chew)? ¿Consume tabaco (fumar o masticar)?
Please check any habits: Por favor marque cualquiera de estos hábitos: o
Nail Biting / Morderse las uñas
o
Lip Biting / Morderse el labio
o
Mouth Breathing / Respirar por la boca
o
Thumb Sucking / Chuparse el dedo pulgar
o
Night Grinding / Rechinar
N/N
Have you ever been in an accident that damaged your teeth? / ¿Alguna vez sufrió un accidente que dañó sus dientes?
o
Y/S
Does your jaw pop or do you hear clicking when chewing?
o
o
N/N
los dientes por la noche
Pencil biting / Morder el lápiz
/ ¿Tiene la mandíbula desplazada hacia adelante o escucha chasquear sus dientes cuando mastica?
o o
Y / S Have you ever received Periodontal (Gum) Therapy? / ¿Ha N / N recibido terapia periodontal (de las encías) alguna vez?
o
Y/S
o
N/N
Do you have any missing teeth? ¿Tiene algún dientes perdidos?
Dentures/Partial Patients / Pacientes con Prótesis Parciales/dentaduras
o o
Y / S Do you wear a denture or partial? / ¿Usa dentadura N / N postiza o prótesis parciales?
o
Y/S
Does your denture cause irritation/soreness? / La
o
N/N
dentadura postiza, ¿le causa irritación/dolor?
How old is your denture or partial? / ¿Qué antigüedad tiene su dentadura postiza o prótesis parcial?
o
Y/S
o
N/N
Are your dentures loose? / ¿Su dentadura postiza está floja?
How would you rate your smile on a scale from 1 to 10, with 10 being the highest? / ¿Cómo calificaría su son-risa en una escala de 1 al 10, siendo 10 la calificación más alta?
Medical History / Antecedentes médicos Primary Care Physician Name / Médico de Atención Primaria
Physician Phone Number / Teléfono del Médico
o
Y/S
o
N / N Are you under a physician’s care? / ¿Se atiende con algún médico?
If you answered yes to any of these questions, please explain: /
o
Y/S
o
N / N Have you ever been hospitalized or had a major operation? / ¿Alguna vez ha sido hospitalizado o ha sido sometido una intervención quirúrgica importante?
Si respondió sí a cualquiera de las preguntas, por favor explique:
o
Y/S
o
N / N Have you ever had a serious head or neck injury? / ¿Ha sufrido alguna vez una lesión de cabeza o cuello grave?
o
Y/S
o
N / N Women: Are you pregnant, trying to get pregnant or nursing? / Mujeres: ¿Está embarazada, intentando quedar embarazada o amamantando?
o
Y/S
o
N / N Do you use controlled substances? / ¿Utiliza sustancias de consumo controlado?
o
Y/S
o
N / N Do you use recreational substances? / ¿Utiliza sustancias recreativas?
Are you allergic or do you react adversely to any of the following? / ¿Es usted alérgico o sufre reacciones adversas a alguno de los siguientes elementos? o
Y/S
o
N / N Aspirin / Aspirina
o
Y/S
o
N / N Penicillin or other antibiotics, please specify: / Penicilina u otros antibióticos, por favor especifique:
o
Y/S
o
N / N Tetracycline / Tetraciclina
o
Y/S
o
N / N Barbiturates, sedatives or sleeping pills / Barbitúricos, sedantes u otras píldoras para dormir
o
Y/S
o
N / N Latex / Látex
o
Y/S
o
N / N Local anesthetics (Novacaine-like medication) / Anestésicos locales (medicamento parecido a la Novacaína)
o
Y/S
o
N / N Sulfa drugs / Fármacos con sulfa
o
Y/S
o
N / N Acrylic / Acrílico
o
Y/S
o
N / N Metal / Metal
o
Y/S
o
N / N Codeine / Codeína
o
Y/S
o
N / N Milk protein / Proteína de la leche
o
Y/S
o
N / N Other, please specify: / Otros, por favor especifique:
(Page 2 of 4 / Página 2 de 4)
Medical History (continued) / Antecedentes Médicos (continuación) Please check any conditions that you currently or previously have had: / Marque las condiciones que tenga actualmente o que haya tenido anteriormente: o o
Y/S o N/N AIDS/HIV Positive Y/S o N/N
o
Y/S o N/N
o
Y/S o N/N
o
Y/S o N/N
o
Y/S o N/N
SIDA/VIH positivo Alzheimer’s Disease Enfermedad de Alzheimer Anaphylaxis Anafilaxis Anemia Anemia Angina Angina Arthritis/Gout Artritis/Gota
o o
Y/S o N/N Diabetes Y/S o N/N
o
Y/S o N/N
o
Y/S o N/N
o
Y/S o N/N
o
Y/S o N/N
Y/S o N/N Hepatitis B or C Hepatitis B o C
o
Diabetes Drug Addiction Drogadicción Easily Winded Se agita fácilmente Emphysema Enfisema Endocarditis Endocarditis Epilepsy or Seizures Epilepsia o convulsiones
Pérdida de peso reciente
Y/S o N/N Herpes
o
Y/S o N/N Recent Weight Loss
o
Y/S o N/N Renal Dialysis
o
Diálisis renal
Herpes o
Y/S o N/N High Blood Pressure Presión arterial elevada
o
Y/S o N/N Hives or Rash
o
Y/S o N/N Rheumatic Fever Fiebre reumática
o
Y/S o N/N Rheumatism
Erupciones o
Reumatismo
Y/S o N/N Hypoglycemia
o
Y/S o N/N Scarlet Fever
o
Y/S o N/N Shingles
Escarlatina
Hipoglucemia o
Y/S o N/N Human Papillomavirus
Culebrilla
(HPV) / Virus del papiloma humano (VPH)
o
Y/S o N/N Artificial Heart Valve* /
o
Válvula cardíaca artificial* N/N Artificial Joint* Articulación artificial*
o
Y/S o
Y/S o N/N Asthma
o
Y/S o N/N Excessive Bleeding
o
Hemorragia excesiva N/N Excessive Thirst Sed excesiva
Y/S o
o
Y/S o N/N Fainting Spells/Dizziness
o
Y/S o N/N Frequent Cough
Asma o Y/S o o
Y/S o
N/N Blood Disease
Enfermedad sanguínea N/N Blood Transfusion Transfusión de sangre
o
Y/S
o
N/N Irregular Heartbeat / Fre-
o
Y/S o N/N Kidney Problems
o
Y/S o
Y/S o N/N Sickle Cell Disease
Células falciformes o
Y/S o N/N Sinus Problem / Problemas en los senos
Problemas renales o
Y/S o N/N Leukemia
Desmayos/mareos Tos frecuente N/N Frequent Diarrhea Diarrea frecuente
o
cuencia cardíaca irregular
paranasales o
Y/S o N/N Sleep Apnea Apnea
Leucemia o
del sueño
Y/S o N/N Liver Disease
o
Y/S o N/N Spina Bifida
o
Y/S o N/N Stomach/Intestinal
Enfermedad hepática o
Y/S o N/N Low Blood Pressure
Espina bífida
Presión arterial baja
Disease / Enfermedades estomacales/intestinales
o
o
Y/S o N/N Breathing Problem
Problemas respiratorios
Y/S o N/N Bruise Easily
Formación de moretones
o
Y/S o N/N Cancer /
o
Y/S o N/N Chemotherapy
o
o
Y/S o N/N Frequent Headaches
Dolores de cabeza frecuentes
Y/S o N/N Glaucoma
Glaucoma
o
Y/S o N/N Hay Fever
o
Y/S o N/N Heart Attack/Failure / Insufi-
Cáncer
o
Quimioterapia
Y/S o N/N Chest Pains
o
Y/S o
o
Y/S o
o o
Dolores en el pecho N/N Cold Sores/Fever Blisters Aftas/ampollas N/N Congenital Heart Disorder Trastorno cardíaco congénito
Y/S o N/N Convulsions Y/S o
Convulsiones N/N Cortisone Medicine Medicación con cortisona
o
Y/S o N/N Lung Disease Enfermedad
o
o
Y/S o N/N Heart Murmur*
o
Y/S o
o
Y/S o
Soplo cardíaco* N/N Heart Pacemaker* Marcapasos cardíaco* N/N Heart Trouble/Disease Problemo cardíaco
o
Y/S o N/N
o
Y/S o N/N
o
Y/S o N/N
o
Y/S o N/N
o
Y/S o N/N
o
Y/S o N/N Hemophilia
o
Y/S o N/N
o
Hemofilia N/N Hepatitis A Hepatitis A
o
Y/S o N/N
Y/S o
Y/S o N/N Stroke / Accidente
cerebrovascular
Y/S o N/N Mitral Valve Prolapse*
Fiebre del heno ciencia/ataque cardíaco
o
pulmonar
Prolapso de válvula mitral* Osteoporosis Osteoporosis Pain in Jaw Joints Dolor en las articulaciones mandibulares Parathyroid Disease Enfermedad paratiroidea Parkinson’s Disease / Enfermedad de Parkinson’s Pins, Rods, Stints or Shunts / Pernos, varillas, soportes y desviaciones Psychiatric Care Atención psiquiátrica Radiation Treatments Radioterapia
*Condition may require medication. / *Estas condiciones pueden requerir medicación
o
Y/S o N/N Swelling of Limbs
Hinchazón de las
extremidades o
Y/S o N/N Thyroid Disease
o
Y/S o N/N Tonsillitis
Enfermedad tiroidea
Amigdalitis o
Y/S o N/N Tuberculosis Tuberculosis
o
Y/S
o
N/N Tumors or Growths Tumores o crecimientos
o
Y/S o N/N Ulcers Úlceras
o
Y/S o N/N Venereal Disease
o
Y/S o N/N Yellow Jaundice
Enfermedad venérea
Ictericia
List any major illness not listed above: / Mencione cualquier enfermedad importante que no se haya mencionado anteriormente:
Please check any medications and/or supplements taken in the past 12 months: / Marque los medicamentos y/o los suplementos que haya tomado en los últimos 12 meses: o
Y/S o N/N Tranquilizer / Tranquilizantes
o
Y/S o N/N Heart medications / Medicamentos para
o
Y/S o N/N Aspirin (daily) / Aspirina (diariamente)
o
Y/S o N/N Nitroglycerine / Nitroglicerina
N/N Insulin or diabetes medication / Insulina
o
Y/S o N/N Anticoagulants (e.g. Coumadin, blood thin-
o Y/S o
el corazón
o medicamentos para la diabetes o Y/S o o
N/N Herbal supplements / Suplementos a
base de hierbas
Y/S o N/N High blood pressure medicine
Medicina para la presión arterial elevada
o
Y/S o N/N Antibiotics or sulfa drugs; if yes, please
o
Y/S o N/N Bisphosphonates (used to treat osteoporo-
specify: / Antibióticos o fármacos con sulfa; En caso afirmativo, por favor especifique:
ners) / Anticoagulantes (por ej. Coumadin) o Y/S o o
N/N Contraceptives / Pildoras anticonceptivas
Y/S o N/N Phen-Fen or Redux / Phen-Fen o Redux
sis, such as Fosamax, Boniva, Actonel and Zometa) / Bifosfonatos (usados para tratar la osteoporosis, como Fosamax, Boniva, Actonel y Zometa)
(Page 3 of 4 / Página 3 de 4)
Medical History (continued) / Antecedentes Médicos (continuación) List all medications/supplements you are currently taking: / Mencione todos los medicamentos/suplementos que esté tomando actualmente:
I have answered all questions to the best of my knowledge. I will notify the dental health provider of any change in my health or medication at each visit. If I have completed this form on behalf of a minor patient, I understand that I must remain in the dental practice during the entire length of each visit and/or procedure(s).
I authorize the dentist/hygienist to use the necessary local/topical anesthesia to perform my treatment in a safe, effective manner during this visit and any future visits. I understand that my failure to provide information on previous adverse reactions may cause unforeseen negative reactions. I release Marietta Smile Gallery, LLC of all liability regarding undisclosed medical history information. He respondido a todas las preguntas según mi conocìmìento. Le avisaré al proveedor de salud dental en caso de cualquier cambio en mi salud o medicamento durante cada visita. Si he completado este formulario en nombre de paciente menor de edad, entiendo que debo permanecer en la clínica dental durante toda la duración de cada visita y/o procedimiento(s).
Autorizo al dentista/higienista a usar el anestésico local/tópico necesario para realizar mi tratamiento de forma segura y efectiva durante esta visita y en las visitas futuras. Entiendo que si no proporciono información sobre reacciones adversas anteriores es posible que se provoquen reacciones negativas inesperadas. Libero a Marietta Smile Gallery, LLC de toda responsabilidad sobre la información de antecedentes médicos que yo no haya mencionado.
Signature of Patient or Guardian / Firma del Paciente o Tutor
If authorized guardian, relationship to patient / Si es el tutor autorizado, relación al paciente
Witness Name / Nombre del testigo
Witness Signature / Firma del testigo
Dentist Name / Nombre del Dentista
Dentist Signature / Firma del Dentista
Date / Fecha
Date / Fecha
FOR OFFICE USE ONLY / SÓLO PARA USO INTERNO
Medical History Update / Actualización de antecedentes médicos Please review your medical history on the previous pages and answer the following questions about any changes to your medical history since your last visit. / Por favor, revise sus antecedentes médicos en las páginas anteriores y responda a las siguientes preguntas sobre cualquier cambio en sus antecedentes médicos desde su última visita. Have there been any changes in
Have there been any recent
Are you presently using any herbs,
your medical history since your last visit? If you answered yes,
changes or additions to your medications? If you answered
teas,
yes, please explain and indicate
yes, please explain and indicate in
in the medications/supplements section above.
the
¿Existe cualquier cambio reciente en sus medicamentos o le
¿Actualmente
please explain and indicate in the medical history section on the previous page. ¿Existe algún cambio en sus antecedentes médicos desde su última visita? Si respondió que sí, por favor explique e indique en la sección de antecedentes médicos de la página anterior.
Patient Initials / Iniciales del paciente
Date / Fecha
Have you been hospitalized for any reason or had joint replace-ment surgery since your last visit? ¿Lo han hospitalizado por alguna razón o le han realizado una operación de reemplazo de articulaciones desde su última visita?
or
hormone
medications/supplements
section above.
utiliza
hierbas,
han recetado otros nuevos? Si
tés, vitaminas o reemplazos hormonales? Si respondió que
respondió que sí, por favor explique e indique en la sección de
sí, por favor explique e indique en la sección de medicamentos/
medicamentos/complementos.
complementos.
Patient Initials Dentist Initials / Iniciales del / Iniciales del paciente dentista
Dentist Initials / Iniciales del dentista
vitamins,
replacements? If you answered
Patient Initials / Iniciales del paciente
Dentist Initials / Iniciales del dentista
Patient Initials / Iniciales del paciente
o
Y/S
o
Y/S
o
Y/S
o
o
N/N
o
N/N
o
N/N
o
N/N
o
Y/S
o
Y/S
o
Y/S
o
Y/S
o
N/N
o
N/N
o
N/N
o
N/N
o
Y/S
o
Y/S
o
Y/S
o
Y/S
o
N/N
o
N/N
o
N/N
o
N/N
Dentist Initials / Iniciales del dentista
Y/S
(Page 4 of 4 / Página 4 de 4) The dentists and hygienists are employees or independent contractors of SmileCare Coast Dental of California, Dental Group of Adam Diasti DDS PC, (Adam Diasti, DDS, Lic. 60596).Coast Dental Services, LLC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. © 2016 Coast Dental. All rights reserved. / Los dentistas e higienistas son empleados o contratistas independientes de SmileCare Coast Dental of California, Dental Group of Adam Diasti DDS PC, (Adam Diasti, DDS, Lic. 60596). Coast Dental Services, LLC cumple con las leyes federales de derechos civiles y no discrimina basado en raza, color, origen nacional, edad, discapacidad, o sexo. © 2016 Coast Dental. Todos los derechos reservados. SC-101493 R 11/15
Patient Financial Agreement / Acuerdo de financiamiento del paciente Marietta Smile Gallery, LLC requires all patients to make financial arrangements with us before we provide treatment. / Marietta Smile Gallery, LLC requiere que todos los pacientes establezcan un acuerdo financiero antes de suministrarles tratamiento. 1.
I understand that full payment is due at the time of service for myself and any party for whom I am financially responsible. Entiendo que debo efectuar el pago completo en el momento de recibir servicio para mi y cualquier persona de la cual yo sea financieramente responsable.
2.
I understand that it is solely my responsibility to confirm which treatments or procedures are covered and/or paid by my insurance (including, but not limited to, any applicable exclusions, deduct-ibles, annual or lifetime maximums). Entiendo que soy el único responsable de confiirmar qué trata-mientos o procedimientos están cubiertos y/o pagados por mi seguro (incluyendo pero sin limitarse a cualquier exclusión, deducible, máximo anual o de por vida que aplique).
3.
I understand that as a courtesy, Marietta Smile Gallery, LLC will attempt to verify my insurance coverage from information that I provide and will file two claims per appointment, in accordance with all contracted agreements with the insurance payor(s). Your personal health information (PHI) may be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you, such as: making a determination of eligibility or coverage for insurance benefits. I am required to pay in full, before treatment is performed, the estimated portion of any procedures or treatment that will not be covered by my insurance. Entiendo que como una cortesía, Marietta Smile Gallery, LLC intentará verificar mi cobertura de seguro a partir de la información que proporciono y presentará dos reclamaciones por cada cita, de conformidad con todos los acuerdos contraídos con el pagador o pagadores del seguro. Es posible que se utilice su información personal de salud (PHI, por sus siglas en inglés), según sea necesario, para obtener el pago por sus servicios de atención médica. Esto puede incluir determinadas actividades que su plan de seguro de salud puede realizar antes de aprobar o pagar por los servicios de atención médica que le recomendamos, tales como: hacer una determinación de elegibilidad o cobertura para prestaciones de seguro. Entiendo que tengo la obligación de pagar en su totalidad, antes de realizar el tratamiento, la porción estimada de cualquier procedimiento o tratamiento que no estarán cubiertos por mi seguro.
4.
I understand that insurance claims will only be filed if I provide Marietta Smile Gallery, LLC with my social security and insurance identification num-bers (if applicable). If I choose not to provide Marietta Smile Gallery, LLC with my social security number, I understand that I must pay in full for all services rendered. It is Marietta Smile Gallery’s policy to require social security numbers and a copy of a government-issued picture identification (driver’s license) for recordkeeping purposes even though that may not be the policy of my insurance carrier. Entiendo que puedo hacer una solicitud de reembolso de seguro sólo si le proporciono a Marietta Smile Gallery, LLC mi número de seguro social y de identificación de seguro (si aplica). Si decido no proporcionar a Marietta Smile Gallery, LLC mi número de seguro social, entiendo que deberé pagar la totalidad de los servicios prestados. Es la política de Marietta Smile Gallery, LLC solicitar los números de seguro social y una copia de una identificación con foto emitida por el gobierno (licencia de conducir) para llevar un archivo aunque probablemente no sea la política de mi proveedor de seguros.
5.
I understand that although I pay my estimated patient balance on the date of service, the insurance estimate may differ from what my insurance carrier ultimately pays. I will be responsible for any amounts not paid by my insurance for any reason, and I may receive a bill/statement for a balance due which will be immediately payable upon receipt. Entiendo que, aunque pague mi balance estimado como paciente en la fecha del servicio, el estimado del seguro puede ser diferente de lo que mi proveedor de seguros pague finalmente. Seré responsable de cualquier cantidad que mi seguro no pague por cualquier razón y probablemente reciba una factura/estado de cuenta por el balance pendiente, el cual deberé pagar inmediatamente en cuanto lo reciba.
6.
I understand that all account balances over 30 days will incur an interest charge at the maximum legal rate allowed.* Entiendo que todas las cuentas con balances que superen 30 días incurrirán un interés a la tasa máxima permitida por la ley.*
7.
I understand that I will be charged the maximum service charge allowed by law for any returned check, electronic authorization or any debit sent or provided to Marietta Smile Gallery, LLC for payment. Entiendo que se me cobrará el cargo de servicio máximo que permite la ley por cualquier cheque, autorización de pago electrónico o débito enviado o entregado a Marietta Smile Gallery, LLC que sea rechazado.
(Page 1 of 2 / Página 1 de 2)
8.
I understand that I must inform Marietta Smile Gallery, LLC, in writing, of any concerns, questions or disputes I may have concerning my treatment or charges in a timely manner but not more than 30 days from either the completion of the procedure or awareness of dispute. Entiendo que debo informar a Marietta Smile Gallery, LLC, por escrito, cualquier inquietud, pregunta o conflicto que pudiera tener en relación con mi tratamiento o con los cargos de manera oportuna pero no más de 30 días después de completado el procedimiento o del conocimiento del conficto.
9.
I understand that if I fail to pay my account upon it becoming due, Marietta Smile Gallery, LLC may report my account to credit rating bureaus or to a collection agency and/or take legal action against me for full payment, including but not limited to all related reasonable attorney’s fees, collection and/or court costs.* Entiendo que si no pago mi cuenta en la debida fecha de pago, Marietta Smile Gallery, LLC puede reportar mi cuenta a las ofiicinas de crédito, a las agencias de colecciones y/o tomar acción legal contra mí por el pago completo, incluyendo pero no limitado a los honorarios del abogado, los gastos de colección y/o los costos judiciales.*
10. I understand that unless patient records are sent directly to another provider, the charge for copies of x-rays is $18.00 and treatment information is $5.00 or the maximum amount allowed by law or my insurance carrier. These fees are subject to change without notice. Entiendo que, a menos que se envíe directamente a otro proveedor el expediente del paciente, el cargo por las copias de radiografías es de $18.00 y por las de información sobre el tratamiento es de $5.00 o la cantidad máxima que permita la ley o mi proveedor de seguros. Estas tarifas están sujetas a cambio sin previo aviso. 11. I understand that Marietta Smile Gallery, LLC currently charges $25.00, or the amount allowed by insurance, for a broken or cancelled appointment unless 24 hours advance notice is given. This fee is subject to change without notice. Entiendo que Marietta Smile Gallery, LLC actualmente cobra $25.00 o la cantidad que permita el seguro, por una cita a la que no asista o cancele, a menos que avise con 24 horas de anticipación. Esta tarifa está sujeta a cambio sin previo aviso. 12. I understand that it is my responsibility to immediately notify Marietta Smile Gallery, LLC of any changes to my address, phone number, work contact information, work status, insurance changes, etc. Entiendo que tengo la responsabilidad de notificar de inmediato a Marietta Smile Gallery, LLC sobre cualquier cambio de dirección, numero de teléfono, información de contacto laboral, situación laboral, cambios en el seguro medico, etc. 13. I authorize payment of the dental benefits otherwise payable to me directly to the below named dental entity. I further authorize Marietta Smile Gallery, LLC to deposit checks received on my account when made payable in my name. Autorizo el pago de los beneficios dentales, que en otras circunstancias se pagarían a mí directamente, a la entidad de servicios dentales que se indica a continuación. También autorizo que Marietta Smile Gallery, LLC deposite en mi cuenta cheques recibidos que estén en mi nombre.
14. I understand that if I discontinue treatment for a requested procedure, including but not limited to, partials, dentures, crowns, bridgework and surgical preparatory work, I remain responsible for paying all lab related costs for materials and services that were incurred before I discontinued treatment. All related costs will be deducted from any refund to which I may be entitled for discontinued treatment and I may receive a bill / statement for a balance due. Entiendo que si interrumpo el tratamiento para un procedimiento solicitado, incluyendo pero no limitándose a, los parciales, las dentaduras, las coronas, la construcción de puente y preparaciones quirúrgicas, yo sigo siendo responsable de pagar todos los costos relacionados con el laboratorio, los materiales y los servicios que fueron incurridos antes de que interrumpiera el tratamiento. Todos los costos relacionados con el tratamiento serán deducidos de cualquier reembolso al cual yo tenga derecho debido a la interrupción del tratamiento y es posible que reciba una factura/estado de cuenta por un saldo pendiente. 15. REFUND OF PRODUCTS: I understand that Marietta Smile Gallery, LLC’s return policy for unopened or unused non-prescription products is thirty (30) days from the date of purchase. Non-prescription products include, but are not limited to, toothbrushes, or other non-prescription merchandise. By law, prescription products cannot be returned which include but are not limited to, whitening products or toothpastes. DEVOLUCIÓN DE PRODUCTOS: Entiendo que la política de devolución de Marietta Smile Gallery, LLC para productos de venta sin receta cerrados o no usados es de treinta (30) días a partir de la fecha de compra. Los productos sin receta incluyen, pero no se limitan a cepillos dentales u otra mercadería de venta sin receta. Por ley, los productos de venta con receta no se pueden devolver y, entre estos tenemos, los productos de blanqueamiento o pastas dentales. I have thoroughly read, understand and agree to the above terms and conditions. / He leído cuidadosamente, entiendo y estoy de acuerdo con los términos y condiciones antedichos.
Printed Name / Nombre con letra de molde
Date / Fecha
Signature of Patient (or authorized guardian) / Firma del Paciente (o su tutor autorizado)
If authorized guardian, relationship to patient / Si es el tutor autorizado, relación con el paciente
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Joint Notice of Privacy Practices This is a Joint Notice of Privacy Practices for: Marietta Smile Gallery, LLC (“MSG”) THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US. Purpose: This Joint Notice of Privacy Practices (“Notice”) presents the information that Federal law requires us to give our patients regarding our privacy practices. We must provide this Notice to each patient beginning no later than the date of our first service delivery to the patient, including service delivered electronically, after April 14, 2003. We must make a good faith attempt to obtain written acknowledgment of receipt of the Notice from the patient. We must also have the Notice available at the office for patients to request to take with them. We must post the Notice in our office in a clear and prominent location where it is reasonable to expect any patients seeking service from us to be able to read the Notice, and on our website. Whenever the Notice is revised, we must make the Notice available upon request on or after the effective date of the revision in a manner consistent with the above instructions. Thereafter, we must distribute the Notice to each new patient at the time of service delivery and to any person requesting a Notice. We must also post the revised Notice in our office as discussed above.
MSG is required to provide you with this Notice pursuant to the privacy regulations implementing the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) (“Privacy Rules”). MSG consists of the entities listed above. These entities are “affiliated covered entities” and an “organized health care arrangement” within the meaning of the Privacy Rules. This Notice applies to all MSG practice locations in California, Texas, Nevada, Florida, and Georgia. OUR OBLIGATIONS We are required by law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal obligations, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect January 1, 2018, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available to you when you first receive services from us after the date the revised Notice becomes effective or upon request.
You may request a copy of our Notice at any time. 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. USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you for our treatment, payment, and health care operations. The covered entities listed above as “MSG” participates in an organized health care arrangement and share protected health information with each other, as necessary to carry out treatment, payment, or health care operations relating to the organized health care arrangement.
For example: Treatment: We may use or disclose your health information to a physician or other health care provider providing treatment to you. Payment: We may use or disclose your health information to your health insurer to obtain payment for services we provide to you. Health Care Operations: We may use and disclose your health information in connection with our health care operations. Health care operations include quality assessment and improvement activities, reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. For example, we may use or disclose your health information in order to conduct an internal assessment of the quality of care we provide.
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Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, to the extent necessary to help with your health care or with payment of your health care, if you agree that we may do so. We may also advise these persons of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your health care. We will also 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.
Disclosures Permitted or Required by Law: We are permitted and in some cases required, by law to make certain other disclosures of health information without your consent. We may disclose your health information, if appropriate, to the following entities under the following circumstances: 1. to public health agencies to satisfy certain reporting requirements, such as births and deaths, certain communicable diseases, child abuse and other public health issues; 2. to health oversight agencies such as governmental auditors, and other agencies when required; 3. to any individual when MSG is ordered by a court or other legal process to do so; 4. to law enforcement officials when necessary for law enforcement purposes and required by law; 5. to a coroner or medical examiner when necessary to enable them to perform their duties; 6. to organ procurement organizations, to enable them to make suitability determination; 7. in cases of emergency; or 8. to researchers if their research has been approved by an institutional review board and they take certain steps to protect your privacy.
Patient Communications: We may use or disclose your health and other information including personal telephone numbers and email addresses to provide you with appointment reminders (such as voicemail messages, auto-dialed messages, notice, reminders, text messages, emails, postcards or letters) or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Billing and collection reminders may include mailed statements, autodialed reminder messages, collection notices and contact by third-party collection agencies. Marketing Health-Related Services: We will not use your health information for external marketing communications without your written authorization. Your Authorization: Other uses and disclosures of your health information will be made if you give us written authorization to do so. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. PATIENT RIGHTS You have certain rights regarding your health information. These rights include: 1. the right to obtain a paper copy of this Notice; 2. the right to receive confidential communications of protected health information; 3. the right to inspect and copy your health information (copies are available for a reasonable fee); 4. the right to request amendments to your health information you believe to be inaccurate; 5. the right to obtain an accounting of MSG’s uses and disclosures of your health information, subject to certain exceptions; 6. the right to request restrictions on our permitted uses and disclosures of your information (although we are not legally obligated to honor this request); and 7. the right to request that communications regarding your health information be sent by alternative means or at alternative locations.
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Acknowledgment of Receipt of Joint Notice of Privacy Practices Reconocimiento de Recibo del Aviso Conjunto de las Prácticas de Privacidad
I have received a copy of the Joint Notice of Privacy Practices of Marietta Smile Gallery. He recibido una copia del Aviso Conjunto acerca de las Prácticas de Privacidad de Marietta Smile Gallery.
Printed Name / Nombre con letra de molde
Date / Fecha
Signature of Patient (or authorized guardian)
Firma del Paciente (o su tutor autorizado)
If authorized guardian, relationship to patient Si es el tutor autorizado, relación al paciente
Witness Name / Nombre del testigo
Witness Signature / Firma del testigo
*YOU MAY REFUSE TO SIGN THIS ACKNOWLEDGMENT* *USTED PUEDE NEGARSE A FIRMAR ESTE RECONOCIMIENTO DE RECIBO*
THIS SECTION FOR OFFICE USE ONLY / ESTA SECCIÓN SÓLO PARA USO INTERNO We attempted to obtain written acknowledgment of receipt of our Joint Notice of Privacy Practices, but acknowledgment could not be obtained because:
Individual refused to sign. Communication barriers prohibited obtaining the acknowledgment. An emergency situation prevented us from obtaining acknowledgment. Other (Please Specify):
Office Location:
Date:
