WELCOME

Patient Information (CONFIDENTIAL)

Responsible Party

Insurance Information

IF YES, COMPLETE THE FOLLOWING:

Patient Medical History

8. Do you have or have you had any of the following?

10. Are you allergic to or have you had any reactions to the following?

12. Women Only:

Patient Dental History

7. Have you ever experienced any of the following problems in your jaw?

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Our staff makes every effort to assist you in understanding your dental benefits. However, it is impossible for us to know all the many different insurance plan benefits from one plan to another. Therefore, we are providing this Notice to inform you of the following responsibilities as they relate to benefit coverage and payment responsibilities by the patient and Dr. Kamran Ruintan/Desert Dental.

Dr. Kamran Ruintan/Desert Dental's Responsibilities:

• Dr. Kamran Ruintan/Desert Dental is NOT responsible for knowing what services are covered by the patient's insurance plan and is NOT responsible for informing the patient whether a particular service is covered. As a courtesy, we do our best to obtain information about your plan's coverage.
• Dr. Kamran Ruintan/Desert Dental will assist the patient in obtaining payment from his/her insurance company by submitting the necessary insurance claims.

Patient's Responsibilities:

• It is the patient's responsibility to know and understand his/her own insurance benefit coverage and limits. The patient is ultimately responsible for payment for all services rendered by Desert Dental at the time of the treatment, and the patient must pay for any services not covered by the patient's insurance company.
• Patients MUST pay their patient portion/copayment at the time of service.
• Patient's may incur, and are responsible for payment of additional charges, if applicable. These charges may include:

           ✔ Charge for returned checks - $35

           ✔ No Show Fee - $25

By signing below, I hereby acknowledge and understand my responsibilities as a patient of Dr. Kamran Ruintan and accept that Dr. Kamran Ruintan/Desert Dental is not responsible for knowing my insurance benefits for services provided.

I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain Patient Rights regarding my protected health information.

I understand that Desert Dental may use or disclose my protected health information for treatment, payment or health care operations - which means for providing health care to me, the patient; handling billing and payment; and, taking care of other health care operations. Unless required by law, there will be no other used and disclosures of this information without my authorization.

Desert Dental has a detailed document called the 'Notice of Privacy Practices'. It contains a more complete description of your rights to privacy and how we may use and disclose protected health information.

I understand that I have the right to read the 'Notice' before signing this agreement. If I ask, Desert Dental will provide me with the most current Notice of Privacy Practices.

My signature below indicates that I have been given the chance to review such copy of the Notice of Privacy Practices. My signature means that I agree to allow Desert Dental to use and disclose my protected health information to carry out treatment, payment, and health care operations. I have the right to revoke this consent in writing at any time, except to the extent that Desert Dental has taken action relying on this consent.

I authorize Desert Dental to speak to the following family members or my personal representative on my behalf: