Drawing of a dental implant
Peter A. Russo, D.D.S., Inc.
Robert Lacrampe D.D.S.
Periodontics and Implant Surgery
18800 Main Street, Suite #201 • Huntington Beach, CA 92648 • (714) 842-2515
(For pharmacy to determine dosage on prescriptions)
GENERAL HEALTH
1.
Are you now and have you always been in good health?
2.
Local anesthetics (Novocaine, etc.) can have interactions with prescription medications, over the couter medications, and even "street drugs". Are you taking ANY drugs or medications?
3.
Have you been under the care of a physician over the past five years?
4.
Do you have any allergies - especially to any drugs or medications?
5.
Have you ever had an operation?
6.
Can you take asprin?
7.
Have you recently gained or lost an excessive amount of weight?
8.
Are you in a high risk group for HIV?
9.
Are you on a special diet?
10.
Do you smoke?
11.
Females only:
Are you pregnant?
Are you post menopause?
Are you currently taking an oral contraceptive?
12.
Do you need to be pre-medicated with antibiotics prior to dental treatment?
13.
When was your last physical examination?
GENERAL HEALTH
Have you ever had or currently have any of the following conditions? Please check the appropriate box.
GINGIVAL HEALTH
1.
Do your gums bleed now or did your gums bleed before?
2.
Have you ever had a gingival abscess (gum boil)?
3.
Do your gums often swell or become tender?
4.
Are any of your teeth loose?
5.
Do you have an unpleasant mouth odor or taste?
6.
Have you ever experienced an unfavorable reaction from dental treatment?
7.
Are you missing any teeth?
8.
Reason for missing teeth
9.
Do you clench or grind your teeth?
10.
Have you ever had gum treatment?
13.
Have you ever had orthodontic (braces) treatment?
DENTAL INSURANCE
To the best of my knowledge, all the preceding answers are true and correct. If I ever have a change in health or medications I will inform you at my next appointment.
FINANCIAL POLICY

ABOUT FINANCIAL ARRANGEMENTS AND DENTAL INSURANCE

We are committed to providing you with the best possible care. If you have dental insurance, we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need our assistance and your understanding of our payment policy.

Payment for services rendered is due at the time services are rendered unless payment arrangements have been approved by our staff. We accept cash, checks, Visa, MasterCard, American Express and Care Credit.

Returned checks and balances older than 30 days may be subject to additional collection fees and interest charges of 1½% per month. Charges will also be made for broken appointments cancelled without 48 hours advance notice for surgical/non-surgical appointments. The fee is $300.00 per hour of surgical time/$80.00 per hour for non-surgical appointments. Please note if you are more than 15 minutes late please consider your appointment cancelled and you will be responsible for the failed appointment fee.

We will gladly discuss your proposed treatment and answer any questions relating to your insurance. You must realize, however, that:

  1. Your insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract.

  2. Our fees are generally considered to fall within the acceptable range by most companies up to the maximum allowance determined by each carrier. This applies only to companies that pay a percentage (such as 50% or 80% of “U.C.R.”). “U.C.R.” is defined as usual, customary, and reasonable.

    This statement does not apply to companies that reimburse based on an arbitrary “schedule” of fees, which bears no relationship to the current standard of cost and care in this area.

  3. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover.
  4. Please be advised that we are not in-network with ANY insurance.
  5. Certain Delta Dental, Blue Cross, Anthem, Blue Shield and United Healthcare plans may pay the patient directly therefore we will collect in full for these carriers and reimburse via check if payment is received in our office.
  6. Please note we are NOT Medicare providers therefore we will not bill Medicare. We have chosen to “Opt Out” of the Medicare Programs.

We must emphasize that, as dental care providers, our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy we extend to our patients, all charges are your responsibility from the date services are rendered. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account.

Please be aware that you are ultimately responsible for any and all charges incurred in our office.

If you have any questions about the above information or any uncertainty regarding your insurance coverage, PLEASE don’t hesitate to ask. We are here to help you.

PATIENT CONSENT FORM
  • Our Privacy Officer (PO) is: Peter Russo, D.D.S.
  • Our Privacy Contact Person (OCP) is: Tiffany
  • Posted in our lobby is our Notice of Privacy Practices. It provides information about how our office may use and disclose your Protected Health Information (PHI).
  • You have the right to review our Notice of Privacy Practices before signing this Patient Consent Form. Please take time to do so now. In addition to the lobby, copies are available at the front desk.
  • You have the right to request that we restrict how your PHI is used or disclosed for treatment, Billing/Payment, or Dental Office Operations. Please submit a Request for Restriction of PHI in writing.
  • We will make every attempt to honor reasonable requests. However, our office does not have to agree with your Request for Restriction of PHI. If we agree to your Request for Restriction of PHI, we shall honor that agreement.
  • You have the right to revoke this Patient Consent Form and may do so at any time in writing. Obviously, a revocation of consent, does not affect disclosures made prior to the date the Revocation was made.
  • Our notice of Privacy Practices may change from time-to-time. If it does you will receive a “revised” Notice on the first visit after changes to the Notice were made.
  • Our office may condition dental treatment upon execution of this Patient Consent Form

I consent to the use and disclosure of my protected health information by your office for treatment, billing/payment, and dental office operations as outlined in your office Notice of Privacy Practices.

Receipt of NOTICE OF PRIVACY PRACTICES
You have the right to refuse to sign this Acknowledgement
On this date I received a copy of this healthcare provider’s NOTICE OF PRIVACY PRACTICES as required by federal law.
Do you give us permission to share your information with family or friends?
FOR OFFICE USE ONLY
On the data above we made a “good faith effort” to obtain patient’s written acknowledgement of receipt of our NOTICE OF PRIVACY PRACTICES.
We were unable to obtain acknowledgement for the following reason: