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Welcome to Our Office

We appreciate your selection of our office for your dental health and esthetic needs!

Our mission is to provide you quality dental care, esthetics and education that will enhance your health and appearance for a lifetime. We aim to exceed your expectations with our care, service and results in a comfortable environment using current technology with proficiency. In addition to being a full-service dental office, we are proud to offer Botox injections (for both medical and cosmetic implications), fillers and the Opus Plasma for skin resurfacing and smoothing.

OFFICE HOURS:

Dental treatment hours are Monday through Thursday 8am to 5pm and Monday and Friday by appointment. The office is closed for major holidays as well as times when our doctors and team are attending continuing education seminars to keep abreast of the latest technology so that we may better serve you. Dental specialty care is available in our office, with subcontracted providers, for your convenience.

EMERGENCIES & SCHEDULING POLICY:

One of our doctors can be reached 24 hours a day for emergencies, simply call our office phone number and follow the directions. In return we ask for your agreement in providing us a full 48 business hours' notice if you need to reschedule an appointment. We respect your time, thank you for respecting ours. A charge will be made for broken/canceled appointments with less than 48 business hours' notice so that we can operate in the most cost-effective and high-quality way that benefits all our patients. Appointments rescheduled less than 48 hours in advance and missed appointments are subject to a minimum $5O/hour broken appointment fee. Your card on file will be automatically run for any missed appointment.

FINANCIAL and “INSURANCE”:

A deposit or insurance co-pay is required to schedule procedures with the doctor. We bill your insurance carrier for services performed on your behalf and accept payment from your carrier for those services. You are responsible for the estimated patient portion when scheduling and any residual due, if any, after insurance pays a claim. Your carrier communicates the same correspondence to us both. When a claim is paid, your card on file will be charged if there is a residual due and we will send an email with corresponding paperwork. As a courtesy to you, if your carrier denies a claim, we will appeal the decision one time. If your carrier denies our appeal, you will be responsible for the unpaid balance. Unpaid balances that are left unpaid in excess of 30 days are subject to a service fee. Accounts with an outstanding balance over 45 days will accrue 18% of the remaining balance. Any additional fees assessed to our office by outside companies (collection agency, attorney, etc.) will be added to your balance

Method for Resolving Discomfort: All parties desire a method for resolving misunderstandings, disputes, discomfort, if any should occur-privately, quickly, and economically and in a friendly, educational manner. We therefore agree to resolve these matters using the communication, negotiation, mediation, and arbitration procedures set forth in the latest edition of the LawForms Integrity Agreement. You may receive a copy of this standard form and information about it from our office.Unless we hear from you to the contrary, we shall assume that you are familiar with the LawForms Integrity Agreement or have taken the time to review and understand it.

I HAVE READ AND UNDERSTAND THE ABOVE “WELCOME TO OUR OFFICE”.

Contact & Insurance Information

In Event of an Emergency:

Nearest Friend or Relative not living with you:

Person ultimately responsible for account:

(Please provide a copy of driver’s license)

I hereby authorize assignment of my insurance rights and benefits directly to the provider for services rendered. I fully understand I am solely responsible for any and all balances not paid by my insurance company within 45 days. Initials

Primary Dental Insurance (if any)

Secondary Dental Insurance (if any)

Personal Health History

Do you have or have you ever had any of the following diseases, medical conditions or procedures?

Oral Cancer Screening

As part of our commitment to your overall health, we screen for oral cancer in our office.

We appreciate your cooperation in answering the questions on the attached page as part of our HPV oral cancer screening process.

HPV oral cancer is harder to discover than tobacco related cancers because the symptoms are not always obvious to the individual who is developing the disease, or to professionals that are looking for it. They can be very subtle and painless. A dentist should evaluate any symptoms that you are concerned with, and certainly anything that has persisted for two or more weeks.

Facts you should know about oral cancer

  • The age group most affected by HPV oral cancer is 25‐50 year olds.
  • HPV contributes to 40‐80% of new oral cancer in the US.
  • Early diagnosis equates to an 80‐90% survival rate and is paramount in treatment success.
  • 100 new cases of oral cancer are diagnosed every day.
  • One American dies every hour from oral cancer.
  • HPV cancer is deep within the tissues and further back in the mouth and throat therefore, we need your help in reporting symptoms.

What we now know about HPV Oral Cancer

  • There are 130 strains of HPV viruses, only a handful are oncogenic (cancer causing).
  • HPV‐16 causes cervical cancer and oral cancer. Men have a 3X greater ratio of HPV cancer over women.
  • HPV virus is transmitted via skin to skin contact (transfer between epithelial cells)
  • The HPV virus infects at least 50% of all people who have had sex at some time in their lives.
  • Those that engage in sexual contact with 5 or more partners are at greatest risk.
  • HPV is related to oral autoimmune conditions and periodontal disease
  • 7% of patients diagnosed with oral cancer have no identifiable cause (other risk factors have yet to be identified).

To adequately screen for HPV-related oral cancer and rule out other conditions, we ask that you answer the following questions:

Medical Insurance Information

Medical Insurance Information (Not Dental Insurance)

Secondary Medical Insurance Information (if applicable)

Sleep Questionnaire


COMPLETELY FILL IN ONE CIRCLE FOR EACH QUESTION - ANSWER ALL QUESTIONS

Have you been diagnosed or treated for any of the following conditions?

Epworth Sleepiness Scale: How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to mark the most appropriate box for each situations. (M.W. Johns, Sleep 1991)

0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

Frequency
Rarely: 0 - 1 times/week
Sometimes: 1 - 2 times/week
Frequently: 3 - 4 times/week
Almost always: 5 - 7 times/week

Insurance Agreement

To our patients requesting that we file your insurance: please read and sign this form (responsible party) for us to accept payment directly from your insurance company.

  • Please remember that professional dental services are rendered and charged to you, the patient, not to an insurance company. You are responsible for the payment of all treatment fees on your account. If your insurance company fails to pay within 45 days, you are agreeing to pay your account in full. We will always continue to re-file paper work, etc. on your behalf and exhaust your options.
  • We will file but cannot accept responsibility for collecting your insurance claim or for negotiating a settlement on a claim. You are responsible for payment of your account.
  • Insurance deductibles and “co-payments” are due when scheduling for such procedure(s).
  • Our office is willing but cannot make a totally accurate estimate of your insurance benefits to be paid since we do not have access to your insurance company records and insurance companies generally will only discuss exact fees with people they insure. Many insurance companies pick and choose randomly what they will and will not cover. It is your sole responsibility to know the terms, agreements and amounts of coverage of your dental/medical insurance benefit contracts.
  • After each insurance claim is paid to our office by your carrier, we request to settle your balance by your credit card on file. We request that you pay any difference indicated to keep your account balance in full. Your insurance company keeps us both informed in writing as claims are paid. We are happy to help with your questions as is your insurance carrier.
  • Thank you! We will make every effort to help you receive full value for any dental “insurance” you participate in. We appreciate all your efforts in keeping your account current so we can focus all our efforts on patient care.

Our conscience and desire for your optimal health drives our treatment plans, not limitations or restrictions imposed by third parties.

Practice Agreement

We invite you to discuss with us any questions regarding our services. The best dental health services are based on a friendly, mutual understanding between provider and patient. Our policy requires that patient portion is paid in full for all services rendered by the time of visit. If account is not paid is full within 45 days of the date of service, regardless of insurance status, you will be responsible for interest charges, collection agency fees and any other expenses or legal fees incurred in collecting your account.

  • I give authorization to the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims or to aid in my treatment at any dental specialist to which I or the patient is referred.
  • I understand the above information and gurantee this form was completed correctly to the best of my knowledge and understand that it is my responsibility to inform this office of any changes to the information that I have provided.
  • I give my permission to have my health discussed with my medical doctors of record and those that i have noted on this form.
  • I understand that, under the Health insurance Portability & Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information. Details available at the front desk.

Acknowledgment of Receipt of Notice of Privacy Practices

Dr. Beth Vander Schaaf

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I, , have received a copy of this office’s Notice of Privacy Practices.

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, as required by law, but acknowledgement could not be obtained because:

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