New Patient Form - Heinrich DDS Forms

Heinrich DDS Forms

1PATIENT INFORMATION

2INSURANCE INFORMATION

3HEALTH HISTORY

4DENTAL HISTORY

5OFFICE POLICY

6HIPAA

Appointment Cancellation Policy
When you schedule an appointment in our office we reserve that time specifically for you. If you need to cancel or reschedule your appointment we require 48 hours advance notice so that we can schedule another patient waiting for treatment. If you miss your appointment or do not give 48 hour notice, there may be a charge applied to your account.
Initial*
Office Financial Policy
Insurance If you have dental insurance, we will make a good faith estimate of the amount your insurance carrier may pay based on the information provided to us. As the insured, it is your responsibility to determine the coverage by your insurance for any dental services provided in our office. As a courtesy, we will file all dental claims on your behalf as well as provide any information required by your insurance carrier to ensure it is processed in a timely manner. If your insurer denies coverage, or if we otherwise do not receive payment within 60 days from filling your claim, the amount will then become due and payable by you. Remember that your coverage is a contract between you and your insurer and/or your employer and your insurer. All questions regarding your insurance benefits should be addressed to your insurance carrier.
Payment The amount estimated to be your portion of treatment, is due at the time dental treatment is provided. We accept payment in the forms of Cash/Check, Visa, Mastercard, Discover, Debit cards (that bear Visa or MasterCard logos), and Care Credit. Patient Responsibility, Assignment and Release I acknowledge my responsibility for the total payment of all services performed in this office in accordance with their regular fees and terms. I understand my responsibility is not modified by whether any third party (insurance) pays for all, part, or none of the charges. I understand that any estimated portion, not covered by insurance is due at the time of service for all services rendered, unless other financial arrangements have been made. I understand that my account becomes delinquent if not paid within sixty (60) days after billing and that at that time a finance charge of 1.0% of the unpaid balance will be charged every month until the balance is paid in full (RCW 19.52.020). I authorize payment to be made directly to Robb B Heinrich DDS PLLC by my insurance company and I accept financial responsibility for all services not covered by my insurance. I authorize release of any medical/dental care information requested by my insurance carrier, and authorize my insurance company to pay insurance benefits directly to Robb B Heinrich DDS PLLC for all dental services rendered. We are here to assist you in any way possible. Please make your questions and concerns known to our team. Our goal is to ensure that you have an exceptional experience!
I have read and understand the Office Financial and Appointment Cancellation Policies.*
Name of Patient*
First Last
Name of Legal Guardian
First Last

STATEMENT OF PRIVACY PRACTICES
Our office is dedicated to protect the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee to ensure that your health information is never compromised is a principal concept of our practice. We may, from time to time, amend our privacy policies and practices but will always inform you of any changes that might affect your rights.
Protecting Your Personal Healthcare Information
We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and Accountability Act and the state of Washington. This includes issues relating to your treatment, payment, and our health care operations. Your personal health information will never be otherwise given to anyone – even family members – without your written consent. You, of course, may give written authorization for us to disclose your information to anyone you choose, for any purpose. Our offices and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality of your records is always protected. Our privacy policy and practices apply to all former, current, and future patients, so you can be confident that your protected health information will never be improperly disclosed or released.
Collecting Protected Health Information (PHI)
We will only request personal information needed to provide our standard of quality health care, implement payment activities, conduct normal health practice operations, and comply with the law. This may include your name, address, telephone number(s), Social Security Number, employment data, medical history, health records, etc. While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law.
Disclosure of your Protected Health Information
We may disclose information as allowed or required by law. We are obligated to provide information to law enforcement and governmental officials under certain circumstances. We will not use your information for marketing purposes without your written consent. We may use and/or disclose your health information to communicate reminders about your appointments including voicemail messages, answering machines, and postcards. You have a right to request and we will honor you written authorization to withhold disclosure to your dental insurance carrier for all services for which you have made full out-of-pocket payment. Any breach in the protection of your personal health information, including unauthorized acquisition, access, use, or disclosure, will be fully investigated, addressed, and mitigated as established by the HIPAA Privacy Rule. You have a right to and will be provided all information relating to any breach involving your personal PHI.
Your Rights as our Patient
You have a right to request copies of your healthcare information; to request copies in a variety of formats; and to request a list of instances in which we, or our business associates, have disclosed your protected information for uses other than stated above. All such requests must be in writing. We may charge for your copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately. You can also notify the U.S. Department of Health and Human Services. Please ask if you have any questions about your privacy rights or the protection of your health information.
10121 N. Nevada St, Suite 302 Spokane, WA. 99218 * 509-467-1117
Acknowledgement of Receipt of Statement of Privacy Practices
I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Dr. Heinrich DDS. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility. Dr. Heinrich DDS reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed to me.
Initial*
Additional Disclosure Authority
In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below
Any member of my immediate family*
- Yes
- No
Spouse only*
- Yes
- No
Other*
- Yes
- No
Please describe:
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MEET DR. HEINRICH

Dr. Heinrich obtained his degree from the University of Washington School of Dentistry in 1993. While attending dental school, Dr. Heinrich also attended the University of Leeds in England for Oral Surgery Externship. He is a three-time graduate of the Pacific Aesthetic Continuum, which emphasizes cosmetic and restorative dentistry. In addition, Dr. Heinrich is a member of the prestigious Spokane Dental Study Club, an ongoing educational forum affiliated with the Seattle Dental Study Club, which focuses on implant and reconstructive dentistry, and a member of the American Academy of Dental Sleep Medicine (AADSM).
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PATIENT INFORMATION

SPOUSE/PARTNER INFORMATION

IN CASE OF EMERGENCY, WHOM MAY WE CONTACT?

Insurance:

Secondary Insurance:

Health History

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Dental History

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Periodontal History

Appointment Cancellation Policy

Office Financial Policy

STATEMENT OF PRIVACY PRACTICES

Protecting Your Personal Healthcare Information

Collecting Protected Health Information (PHI)

Disclosure of your Protected Health Information

Your Rights as our Patient

10121 N. Nevada St, Suite 302 Spokane, WA. 99218 * 509-467-1117

Acknowledgement of Receipt of Statement of Privacy Practices

Additional Disclosure Authority

MEET DR. HEINRICH