Patient Intake Form

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Personal Information Release & Consent

We are committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information we collect, use, and disclose. In addition to the circumstances described in this form, we also collect, use, and disclose personal information when permitted or required by law.

We collect information from our patients such as names, addresses, telephone numbers, and email addresses (collectively referred to as “Contact Information”). Contact information is collected and used for the following purposes:

To open & update patient files
To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts
To process claims for payment or reimbursement from third-party health benefit providers and insurance companies
To send reminders to patients concerning the need for further dental examination or treatment via email and text
To send patients informational material about our dental practice

Contact Information is disclosed to third-party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf.

“Financial Information” may be collected in order to make arrangements for the payment of dental services.

We collect information from our patients about their health history, physical condition, and dental treatments (collectively referred to as “Medical Information”). Patient’s Medical Information is collected and used for the purpose of diagnosing dental conditions and providing safe dental treatment.

Patient’s Medical Information is disclosed:

To third-party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment on all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf
To other dentist’s and dental specialists, where we are seeking a second opinion and the patient has consented to us obtaining the second opinion
To other dentist’s and dental specialists if the patient, with their consent, has been referred to us by the other dentist or dental specialist for treatment
To other dentists and dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion
To other health care professionals such as physicians if the patient, with their consent, has been referred to us by the other health care professional for either a second opinion or treatment

I consent to the collection, use, and disclosure of my personal information or that of my dependents as set out above. I consent to the taking of photographs and x-rays by Riverstone Dental, as they are a necessary part of record keeping.*

Yes

Release of Information

I hereby assign my benefits, payable from insurance claims submitted electronically, to Riverstone Dental Clinic, and authorize payment to their office.
I understand that my insurance policy is a contract between myself, my employer, and the insurance company. I understand that Riverstone Dental Clinic is NOT a party to this contract.
I understand that I am responsible for the fees of Riverstone Dental Clinic, and not what my insurance allows or considers “usual, customary, and reasonable,” all of which vary from one insurance company to another.
I understand that although Riverstone Dental Clinic may estimate my insurance benefits, they are not responsible for the accuracy of those benefits. Providing information regarding benefits, and benefit amounts, limitations, exclusions, waiting periods, etc, is entirely my responsibility.
I understand that all charges not paid by insurance are entirely my responsibility.

Health Benefits

Do you have Health Insurance?*

Yes

Insurance Company*

Group Plan Number*

Certificate/Subscriber ID#*

Subscriber Name*

Subscriber Birthdate

Do you have Secondary (additional) Health Insurance?

Yes

Secondary Insurance Company*

Secondary Group Plan Number*

Secondary Certificate/Subscriber ID#*

Secondary Subscriber Name*

Secondary Subscriber Birthdate

Financial Policy

On our patient’s behalf, our dental office will submit the primary and secondary insurance claims and request that your benefit company pays our office directly for your services. Our patients are required to pay any remaining balance at the time of the appointment, if the benefit company does not pay in full. In the event that your benefits do not tell us what they will be paying, we do require a credit card be left on file so that we can apply the difference once payment is received.

If your policy does not allow for payment directly to our office, the patient is responsible for payment in the full amount at the time of the appointment. We will submit dental claim forms on your behalf and have the insurance company reimburse you directly. If you do not have any dental benefits, we do require payment in full at the time of your appointment.

Consent

I consent to the above information, disclosure and financial policies*

Yes

Your Name*

Signature Date

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Welcome

Patient Information

Emergency Contact Information

Dental History

Medical History

Personal Information Release & Consent

Release of Information

Health Benefits

Financial Policy

Consent

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