Thank you for visiting ken m lepinskas dds. We want your visit to be pleasant and comfortable.Please help us by completing this form
Personal Details
Appointment date:
Title:
First Name:
Last Name:
Date Of Birth:
Social Security Number:
Gender:
Marital Status:
Address
Street Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Email Address:
Driver's License:
Emergency Contact Information
Name:
Relation:
Home Phone:
Work Phone:
Address:
City:
State:
Zip Code:
Professional Information
Employer Name:
Position:
Employer Address:
City:
State:
Zip Code:
Spouse Information
Spouse Name:
Date Of Birth
Phone Number:
Employer:
Primary Insurance Information
Secondary Insurance Information
Responsible Person for Account
Name:
Relation
Home Phone:
Social Security number:
Address:
City:
State:
Zip:
Employer:
Work Phone:
Billing Address:
City:
State:
Zip:
Are you allergic to any of the following?
Do you or Have you experienced the following ?
Current/Previous Dental:
Last visit:
Treatment Authorization
The information on this page is correct to the best of my knowledge. I authorize and give consent to perform dental services agreed between doctor and patient and/or parent or guardian to be necessary or advisable including the use of local anesthesia and other medication as indicated. I certify to the above statements regarding my medical condition.
The information on this page is correct to the best of my knowledge.
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PATIENT OR PARENT/GUARDIAN SIGNATURE |
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DATE & IP ADDRESS |
Office Financial Policy
Payment is expected at time of service. We will accept cash, check, or credit card. Checks accepted with valid driver’s license only.
We accept insurance. We will file your claims at no charge. It is the patient’s responsibility to provide us with current insurance information.
If any payment from an insurance company becomes 30 days past due, you will be immediately billed for the entire balance.
We will file pre-treatment estimates, AT YOUR REQUEST ONLY. Please be aware that some insurance companies may not honor a pre-treatment estimate or may alter it. In all cases it may delay important dental care.
Not all services are covered by insurance. In the event your insurance plan determines a service to be “not covered”, you will be responsible for the complete charge. Our staff can never guarantee your eligibility and coverage.
Insurance limitations and regulations vary with all insurance plans. Therefore, if your insurance plan denies a service, you will be responsible for the complete charge. We do not base your treatment plan on what your insurance plan covers or doesn’t cover. We are working for you, not the insurance company.
Past due accounts may be turned over to a collection agency. Any fees incurred due to this, will be added to the outstanding balance. This may include late fees, collection agency fees, court fees etc.
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Missed Appointment Policy
Due to the high number of patients requiring dental care, waiting times for appointments can be long. Because of this, we enforce a missed appointment policy to ensure that other patients receive care in a timely manner. Missed appointments and appointments cancelled without 24-hour notice are subject to a cancellation fee.
Consent for Internet Communications
I grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured web site for the dental practice.
I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the web site on my behalf. I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES.
I have read the information above regarding the secured uploading of patient information to the web site for the dental practice, and grant the dental practice permission to securely upload my patient information to the web site. This will serve as my electronic signature.
Recieving Appointment Reminders Via Email and Text
Please check a source in which you would like to recieve appointment reminders.
Email Address(if applicable)
Cell Phone(if applicable)
We use this information to provide you with excellent treatment. We may disclose Patient Health Information (PHI) to third parties that perform services for ken m lepinskas dds in the administration of your benefits in accordance with HIPAA. These parties are required by law to sign a contract agreeing to protect the confidentiality of your PHI. Your PHI may be disclosed to an affiliate that performs services for ken m lepinskas dds in the administration of your benefits. Our affiliates do not sell, share or rent our users’ personally identifiable information unless required by law, do not send and e-mail or other communications without user permission, and do not send spam.
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