15051 Cleveland Road
Granger, IN 46530
Mon: 7:40 AM–5:00 PM
Tue: 7:40 AM–5:00 PM
Wed: 7:40 AM–4:00 PM
Thu: 7:40 AM–5:00 PM
Fri: 7:40 AM–5:00 PM
Notice of Privacy
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MEDICATIONS (IF EXTENSIVE, PLEASE PROVIDE ATTACHED LIST)
Medications (if extensive, please provide an attached list)
If your list of medications is extensive, please use the attach feature located at the end of the form before submitting it.
Are you now under the care of a physician?
Have you ever had any serious illness, operation, or hospitalization?
Do you have unhealed/recurrent injuries, inflamed areas, growths, or sore spots in/around mouth?
Have you had an artificial joint replacement (knee, hip, shoulder, etc.)?
Have you ever had any complication w/surgeries?
Have you taken bisphosphonates for osteoporosis or chemotherapy for multiple myeloma or other cancers (Reclast, Fosamax, Boniva, Actonel, Aredia, or Zometa)?
Are you taking any blood thinners?
Have you had any serious problems associated with previous dental treatment or general anesthetic?
Are you wearing contact lenses?
Are you wearing any removable dental appliances?
Do you wish to talk with the doctor about anything privately?
Do you have, or have you had, any of the following diseases or problems?
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CONSENT FOR CARE AND TREATMENT
I, the undersigned, do hereby agree and give my consent for Granger Oral Surgery & Dental Implants to provide medical/dental evaluation, care, and/or treatment to me or someone for whom I am authorized to make medical decisions. This evaluation, care, or treatment is considered medically necessary and proper in the diagnosing or treatment of his/her/my physical condition. I understand that even though I give my consent for evaluation, care, or treatment, I may refuse any of these services at any time.
FINANCIAL POLICY STATEMENT
At Granger Oral Surgery & Dental Implants, we make every effort to provide you with the finest care and most convenient financial options. We will work to maximize your dental benefits for covered procedures. Payment is due at the time services are rendered. As a courtesy, we will file a claim with your dental benefit plan. Please remember that dental benefits are considered a reimbursement method for patient payments and are not a substitute for services rendered. If your dental benefit plan does not pay on your claim within 30 days from the date of service, you become responsible for any outstanding balance on your account.
We have opted out of the Medicare program and are not providers for Medicaid. If you have Medicare benefits, we ask that you let us know so you can sign a contract explaining in detail the terms of opt-out status.
In the event that the account is not paid in accordance with the financial arrangements made at discharge or within 90 days, the account will be turned over to a collection agency. The patient or responsible party will be responsible for all processing fees and collection costs, including reasonable attorney fees, if the account is placed in the hands of a collection agency or attorney.
BENEFIT ASSIGNMENT/RELEASE OF INFORMATION
I hereby authorize my insurance company to release all information necessary for payment of benefits. I hereby assign payment of benefits by my insurance company to Granger Oral Surgery & Dental Implants.
A Notice of Privacy (NP) has been made available to me by Granger Oral Surgery & Dental Implants. The Notice of Privacy describes how my health information may be used or disclosed and my rights under the Health Insurance Portability and Accountability Act (HIPAA).
You may leave messages containing protected health information or finances on my voicemail:
I give permission for the release of account and health information to the following individuals:
I further authorize Granger Oral Surgery & Dental Implants to communicate with me electronically through the email address provided.
CONSENT FOR DIGITAL IMAGES
Dr. Anderson and the Granger Oral Surgery team may take photographs, videos, and/or digital records of my face, jaws and teeth before, during, and after treatment to be used for records, research, and education including lectures, seminars, demonstrations, professional publications such as journals or books or various electronic publications. I understand that if I consent, when the photographs, videos, and /or digital records are used, my name or other identifying information will be kept confidential and that I may revoke consent for obtaining and using future imaging in writing.
*By submitting this document, I am hereby indicating that I have read and understand the above and answered the questions to the best of my ability. I understand that it is my responsibility to fill out this form correctly and completely. To falsify or omit information could seriously harm Dr. Anderson’s ability to provide care safely.