Coal City Dental

Coal City Dental


Please enter the patient's name below:
Patient Information
Employer Name
Primary Insurance
Secondary Insurance
All of the above information is correct to the best of my knowledge. I authorize use of this form on all my insurance submissions and I authorize the release of information to all my insurance companies. I understand that I am responsible for my bill. I authorize the dentist and staff to act as my agent in helping me to obtain payment from my insurance companies. I authorize payment to the dentist and staff. I permit a copy of this authorization to be used in place of the original. I give the dentist, staff, and/or other agents express prior consent to contact me at any/all phone numbers, including cell numbers (by phone call or text message) and email addresses, for the purpose of treatment, insurance, or payment.
I hereby authorize the doctor or designated staff to take X-rays, study models, photographs, and other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the dental needs of the above-named patient.
Upon such diagnosis, I authorize the doctor or designated staff to perform all recommended treatment mutually agreed upon by us and to employ such assistance as required to provide proper care.
I agree to the use of anesthetics, sedatives, and other medications as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
I have read, understood, and agree to the above treatment policy.
Thank you for taking the time to understand our policies. For any questions about fees, financial policies, or your responsibilities, please ask one of our staff members for clarification. Please note that regular examination appointments are required to be considered a current patient in our office. If it has been over one year since your last visit, you may be required to re-establish your relationship with our office prior to receiving any services, including emergency care.

Billing and Insurance Deposits, deductibles, and/or co-payments are due on the date of service. We do our best to provide accurate information, but due to the nature of medical care and insurance benefits, ESTIMATED AMOUNTS given are subject to change.
We will bill your PPO insurance, but coverage may vary based on our network status, if applicable. We do not accept HMO or State Welfare/Medicaid programs. Your dental insurance plan is a contract between you, your insurance company, and employer, if applicable. If a balance remains after your insurance has paid, or balance remains unpaid beyond 90 days, you will be responsible for payment of remaining balance.

If your insurance company pays you directly, you will be asked to pay in full. (NOTE: This is common with Delta Dental due to network status.)

Returned/Insufficient Funds checks are subject to a $25.00 service fee in addition to initial balance.

If no notice, or less than 24 hours notice is given to cancel/change an appointment, an automated charge of $50 will be added to your account. If notice is given, this fee may be waived. If you are more than 10 minutes late, you may be asked to reschedule. We will also do our best to respect your time by keeping on-schedule.

If your balance remains unpaid beyond 90 days, your balance may be submitted to a financial collection agency, and a 50% fee of your total balance will be added for their costs. This agency will report to the credit bureau(s), and may take legal action if the balance is not resolved.


If under 18, you must be accompanied by a legally and financially responsible adult. If there is a reason this is not possible, it must be discussed prior to your visit so appropriate arrangements can be made.


I hereby authorize payment directly to this practice of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of the dental treatment. The information provided is correct to the best of my knowledge. I understand that a breach of these policies may result in removal from care in this office. By signing, I affirm that I accept financial responsibility for this patient, and I understand and agree to all above listed policies.

Last Dental Visit
Dental History
Medical Background
Medical History
Women Only:


I affirm that the above information is correct to the best of my knowledge. I understand that providing incorrect information can be dangerous to my (or the patient's) health. It is my responsibility to inform the dental office of any changes in medical status. I understand that the above information is necessary to provide me with dental care in an efficient and safe manner. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release information to you.

HIPAA Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

Please review the following carefully. The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. The Act gives you, the patient, significant new rights to understand and control how your information is used. HIPAA provides penalties for covered entities that misuse personal health information.

As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

We may use and disclose your medical records for several purposes, including treatment, payment, defense of legal matters, to family and friends, and health care operations:

* Treatment includes providing, coordinating, and/or managing health care related services by one or more health care providers. An example of this would include teeth cleaning services.

* Payment includes such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a claim for your visit to your insurance company for payment.

* Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review. We may also create and distribute de-identified health information by removing all references to individually identifiable information.

* To Your Family and Friends: We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare. Before we disclose your health information to these people, we will provide you with an opportunity to object to our use or disclosure. If you are not present, or in the event of your incapacity or an emergency, we will disclose your medical information based on our professional judgment of whether the disclosure would be in your best interest. We may use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, X-rays, or other similar forms of health information. We may use or disclose information about you to notify or assist in notifying a person involved in your care, of your location and general condition.

In some limited situations, the law allows or requires us to use/disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:

* When a state or federal law mandates that certain health information be reported for a specific

purpose * For public health purposes, such as contagious disease reporting, investigation or surveillance, and notices to and from the federal Food and Drug Administration regarding drugs or medical devices

* Disclosures to governmental authorities about victims of suspected abuse, neglect, or domestic violence

* Uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws

* Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies

* Disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else

* Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations Uses or disclosures for health-related research

* Uses or disclosures for health-related research

* Uses and disclosures to prevent a serious threat to health or safety

* Uses or disclosures for specialized government functions, such as for the protection of the president or high-ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service

* Disclosures of de-identified information

* Disclosures relating to worker's compensation programs

* Disclosures of a 'limited data set' for research, public health, or healthcare operations

* Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures

* Disclosures to 'business associations' who perform healthcare operations for our office and who commit to respect the privacy of your health information

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. If you wish to be omitted from any mailings please provide a written notice. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.

* The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.

* The right to inspect and copy your protected health information.

* The right to amend your protected health information.

* The right to receive an accounting of disclosures of protected health information.

We are required by law to maintain the privacy of your protected health information and provide you with notice of our legal duties and privacy practices with respect to protected health information.

This notice is effective as of September 5, 2019, and we are required to abide by the terms of the Notice of Privacy Practices currently in effect.

We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

If you think that we have not properly respected the privacy of your health information or that your privacy protections have been violated, you have the right to file a written complaint to us or the U.S. Department of Health and Human Services, Office for Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.

For more information about HIPAA and/or to file a complaint, please call or visit or office or contact:

The U.S. Department of Health & Human Services, Office for Civil Rights
200 Independence Avenue, S.W.
Washington D.C. 20201
(202) 619-0257 Toll Free: 1-877-696-6775
Patient Acknowledgement of Receipt of Notice of Privacy Practices Pursuant to HIPAA and Consent of Use of Health Information
For more information, contact:
The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
(877) 696-6775 (toll-free)

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