We are pleased to welcome you to our practice! To further assist your dental needs, please fill out the following form completely. If you have any questions we will be glad to help. We look forward to working with you in maintaining your dental health.
In case of an emergency, who should we notify?
Whom may we thank for referring you?
Name of Previous Dentist
Date of previous dental visit
Name of your Primary Care Provider
Date of last visit with your primary care provider
Main Subscriber on Account
Relationship to Patient
Address (If different from patient’s)
Main Subscriber’s Employer
Insurance Company Name
Insurance Company’s Contact Number
Dental Health History
Do you have, or have you had any of the following? (check all that apply)
Apprehension about dental treatmentProblems with previous dental treatmentGag easilyWear denturesFood catches between your teethDifficulty chewing your foodChew on only one side of your mouthAvoid brushing any part of your mouth because of painGums bleed easilyGums bleed when flossingGums feel swollen or tenderNotice slow-healing sores in or around your mouthFeel twinges of pain when your teeth come in contact with:Hot foods or liquidsCold foods or liquidsSour foodsSweet foodsTake fluoride supplementsClench or grind your teeth frequentlyJaw gets stuck so that you can’t open freelyPain when you chew or open wide to take a biteEaraches or pain in front of your earsJaw symptoms or headaches upon awaking in the morningTake medications for pain or discomfort (pain relievers, muscle relaxants, antidepressants)Temporomandibular (jaw) disorder (TMD)Pain in the face, cheeks, jaws, joints, throat, or templesUnable to open your mouth as far as you wantAware of an uncomfortable biteHad a blow to the jaw (trauma)
Assignment of Benefits
Our office will accept an assignment of benefits from your insurance company with the provisions listed below. It is important to understand that the agreement regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for treatment regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our office policies governing insurance claims.
• Although we are willing to complete insurance forms and submit a claim on your behalf, we do not accept responsibility for the outcome of the transaction. Completing insurance forms and filing to your insurance company on your behalf is a courtesy we extend to you in an effort to save you time and to facilitate payment to our office from your insurance company. By having our office process your insurance forms, it is important that you understand that this does not eliminate your financial obligation for your treatment.
• We require you to sign this agreement and/or other necessary assignment documents that may be requires by your insurance company. This instructs your insurance company to make payments directly to our office.
• We require you to pay the estimated co-payment, which is the amount not covered by your insurance company, at the time treatment is rendered. The co-payment is ONLY an estimate of charges and may be found to be insufficient after review by your insurance company.
• Insurance payments are ordinarily received within 30-40 business days from the time of filing the claim. If your insurance company does not pay within 90 days, you will be responsible for the entire balance at that time. You will be reimbursed if payment is made afterwards.
• Our office does not guarantee that your insurance company will pay for treatment you receive from our practice. We perform routine insurance billing procedures upon verification of coverage. However, if for any reason your claim is denied, you will be responsible for paying the full amount for the treatment rendered.
• Returned checks are subject to a $50 admin fee. All balance older than 60 days will be subject to a collection action fee.
• There is a $75 charge for all no-show and cancellations of scheduled dental appointments WITHOUT a 24 hour notice.
• We respect our patients’ time so in order to provide timely, professional care, we do have a 15 minute rescheduling policy. Patients who are 15 minutes late to their scheduled appointments will be rescheduled.
I HAVE READ AND ACCEPTED THE TERMS AND CONFITIONS OF THIS ASSIGNMENT OF BENEFITS AGREEMENT AND OFFICE POLICY. I AUTHORIZE MY INSURANCE COMPANY TO PAY MY DENTAL BENEFITS DIRECTLY TO DR. KAMILA HUSAIN.
Consent for Use Disclosure of Health Information
Purpose of consent: By signing this form, you will consent to our use and disclosure of your health information to carry out treatment, payment activities, and health operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our Notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we may make of your health information, and of other important matters about your protected health information. We encourage you to read it carefully and completely before signing this consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting: Dr. Kamila Husain DDS and/or Staff at 1013 Dairy Ashford Rd. Houston, TX 77079, (713)800-4200 email@example.com
Right to Revoke: You will have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the contact person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this consent.
I, , have fully had the opportunity to read and consider the contents of this consent form. I am giving my consent to your use and disclosure of my protected health information to carry our treatment, payment activities and healthcare operations.
YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT
I consent that Dr. Kamila Husain may use photographs of me on their social media page which includes but is not limited to their Facebook page. I understand that these images will not be used for any other commercial purposes.
Thank you for choosing U Sparkle Dental. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of our mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.
- Cash, Check, Visa, MasterCard, or Discover Card
- We offer a 5% courtesy accounting adjustment to patients who pay for their treatment with cash or check prior to completion of care for treatment plans of $1,500 or more
- NO INTEREST Payment Plans from Care Credit (up to 12 months):
Allows you to pay overtime with NO INTEREST
Convenient, low monthly payment plans are also available
No annual fees
Our dental practice requires payment prior to the beginning of your treatment.
For patients with dental insurance, we are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement for your treatment.
A fee of $75 is charged to patients who miss or cancel an appointment without a 24 hour notice.
Our dental practice charges $50 for all returned checks.
If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need.
Patient, Parent or Guardian Signature
Patient Name (Please Print)