Patient Medical History

Name

Date of Birth

SS#

Today’s Date

Home Phone

Cell Phone

Work Phone

Email Address

May we correspond via email or text?

City

State

Zip

Address

Spouse Name # (parent if minor)

Spouse or Parent's Phone Number

Name of your insurance company?

Is Insurance under

INSURANCE POLICY HOLDERS INFORMATION

Name

Social Security or ID

Date of Birth

Employers Name

Employers Phone

Employers Address

Insurance Authorization; I hereby authorize Paul W.Jakubowski, DDS to furnish copies of my records to my insurance company upon request. 1 hereby assign to Paul W.Jakubowski, DDS payments for dental services rendered to myself or my dependent. A copy of this signature is as valid as the original. I agree to be responsible for any co-pays, deductible anchor charges not covered by my insurance.

Signature

Print Name

Please Select EACH Condition that Pertains to You, Previously or Currently. Your answers are for our records ONLY and will be considered Confidential

Other conditions not listed above?

Medications presently taking?

Allergic to ANY drugs? (Please list)

Do you require Pre-medication with antibiotics prior to dental treatment?

Any conditions relevant to your visit today?

Patient Signature (I certify the above information is correct)

Date

Office Financial And Insurance Policies

Thank you for entrusting us with your dental care. We are making every effort to keep our cost down so that we can pass those savings on to you.

PLEASE READ AND SIGN

Full Payment is expected at the time services are rendered unless arrangements are made prior to your visit. We accept VISA, MASTER CARD, AMERICAN EXPRESS, DISCOVER and CARE CREDIT. There will be a $35.00 charge on all returned checks.

As a courtesy we will file your insurance. It is your responsibility to make sure that we receive prompt payment from them as you are ultimately responsible for the claim. Most insurance will not cover 100% of all dental expenses.

Please note that we are OUT OF NETWORK for all insurance companies, meaning we are a non-participating provider. Services will be paid at a “Usual and Customary Rate” by your insurance company and you are responsible for any remaining balance. Also, please understand that dental insurance is a contract between the patient and the insurance company and not a contract between the insurance company and the office. There are some insurance companies that will not assign benefits to us, meaning they will only send payment to the patient.

Any balance due on your account after 90 days will incur a 1.5% finance fee.

There will be a $35.00 charge for scheduled appointments canceled without 24 hour prior notice or failure to show up for a scheduled appointment.

For patients that would rather file their own insurance, the receipt you are given at the end of your visit contains all the information your insurance company needs to file your claim.

Again, thank you for choosing us. We will continue to strive to provide the best care possible in a professional, caring and courteous environment.

Your referral is the best compliment we could receive.

Signature

Date

Authorization For Disclosure Of Protected Health Information

I Authorize The Use / Disclosure Of Health Information About Me As Described Below

Patient Name:

Patient's Date of Birth:

Patient's SSN:

A. Person(s) or Organization(s) authorized to provide the information: DR. PAUL JAKUBOWSKI OR AUTHORIZED STAFF MEMBER:

B. Person(s) or Organization(s) authorized to receive the information:

C. Specific description of the information that may be used or disclosed

D. Specific description of how the Information will be used:

I understand that this authorization will expire on (insert date).
I understand that I may revoke this authorization (except to the extent that action was already taken in reliance on the signed authorization) at any time by notifying (Insert name practice) In writing.
I understand that I can refuse to sign this authorization and that my refusal will not affect my ability to obtain treatment, payment or my eligibility for benefits (If applicable).
I may inspect or copy any Information used or disclosed under this agreement.
I understand that if the person or organization that receives the information is not a health care provider or plan covered by federal privacy regulations, the information described above may be re-disclosed and would no longer be protected by these regulations.

Patient's Signature or Patient's Representative

Date

Printed Name of Patient's Representative

Relationship to Patient

Patient Medical Form

Patient Medical History

Office Financial And Insurance Policies

Authorization For Disclosure Of Protected Health Information