These forms represent the standard new patient documentation package required to establish Firlik Family Dentistry and Airway Health Care care. They are designed to ensure comprehensive patient care, protect patient privacy, and develop clear financial and administrative policies.
Patient Information: This basic demographic and contact form collects your personal information, emergency contacts, and insurance details. It ensures that the practice has accurate contact information and proper insurance documentation for billing purposes.
Notice of Privacy Practices Acknowledgement: This form outlines your rights under HIPAA (Health Insurance Portability & Accountability Act) regarding how your protected health information can be used and disclosed. It explains how your information may be used for treatment, payment, and healthcare operations.
Financial Policy: This document explains the practice’s payment policies, insurance procedures, and cancellation requirements. It details accepted payment methods, insurance claim procedures, and the 48-hour cancellation policy, which includes an associated $50 fee for missed appointments.
Medical History: A comprehensive health questionnaire that covers your medical conditions, allergies, medications, and relevant health history. This information is crucial for ensuring safe dental treatment and understanding any medical conditions affecting dental care.
Dental History: This form gathers information about your dental care habits, current dental concerns, and previous dental work. It helps the dentist understand your oral health needs and any specific issues that need attention.