Patient Registration and Arbitration Agreement Patient Details

Patient Registration and Arbitration Agreement Contact Information

Patient Registration and Arbitration Agreement Emergency Contact Information

Patient Registration and Arbitration Agreement Responsible Party's Information

Patient Registration and Arbitration Agreement Primary Insurance Details

I hereby authorize assignment of my insurance benefits directly to the provider for services rendered.

I fully understand I am solely responsible for any balance not paid by my insurance company.

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(Your IP Address :IP:3.235.41.241 )

Patient Registration and Arbitration Agreement Dental Information

  •  Yes
  •  No
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Do you have any of the following?

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  •  Aspirin
  •  Penicillin
  •  Codeine
  •  Acrylic
  •  Metal
  •  Latex
  •  Local Anesthetics
  •  Any other Allergies

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

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Women

  •  Yes
  •  No
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  •  No

To the best of my knowledge, all of the preceding answers are true and correct. If I ever have a change in the condition of my health or if my medications change, I will, without fail, inform the doctor at my next appointment.

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(Your IP Address :IP:3.235.41.241 )

Patient Registration and Arbitration Agreement

  •  As a courtesy, we attempt to confirm most appointments 48 hours in advance. However, if we are unable to reach you, keeping your appointment is your responsibility.
  •  We require an advanced 24 hour notice of cancellation or request to reschedule an appointment.
  •  Failure to reschedule or cancel your appointment in this time frame will result in a charge of $50 per 1/2 hour appointment(s) for general and $100 per 1/2 hour appointment(s) with specialists. Please note that all Monday appointments shall be canceled by 5 P.M. Friday or a broken appointment charge will be applied.
  •  As a condition of treatment by this office, financial arrangements must be made in advance. We depend upon timely reimbursement for the costs incurred in rendering care. Financial responsibility on the part of each patient must be determined before treatment.
  •  All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed unless other arrangements are made.
  •  Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any insurance payment to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.
  •  A service charge of 11⁄2% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previous written financial arrangements are satisfied.
  •  I understand that any fee estimate for dental care can only be extended for a period of six months from the date of the patient examination.
  •  In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment, or within five (5) days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due. I further agree that a waiver of any breach of time or condition hereunder shall not constitute a waiver of any other term or condition and I further agree as the responsible party to pay all costs including but not limited to outside collection fees, bank fee, penalties and reasonable attorney fees.

I grant permission to you or your assignee, to telephone me to discuss this statement or my treatment.

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(Your IP Address :IP:3.235.41.241 )

Patient Registration and Arbitration Agreement HIPAA Consent

HIPPA Consent

I give this practice my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies and for health care operations like quality reviews.

I have been informed that I may review the practices Notice of Privacy Practices (for a more complete description of uses and disclosures) before signing this consent. I understand that this practice has the right to change their privacy practices and that I may obtain any revised notices at the practice.

I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that the practice is not required to agree to the request. If the practice agrees to my requested restriction, they must follow the restriction(s).

I also understand that I may revoke this consent at any time, by making a request in writing, excluding any for information already used or disclosed.

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(Your IP Address :IP:3.235.41.241 )

Patient Registration and Arbitration Agreement Physician Patient Arbitration Agreement

Article 1Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompletely rendered, will be determined by submission to arbitration as provided by California State law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2All claims must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to ant claim. In the case of any pregnant mother, the term "patient" herein shall mean both the mother and the mother's expected child or children.

All claims for monetary damages exceeding the jurisdiction limit of the small claims court against the physician, and the physician's partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filling of ant action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim.

Article 3Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party's pro rata share of the expenses and feas of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party's own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law.

Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrators.

The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.

The parties agree that provisions of California law applicable to health care providers shall apply to disputes within this arbitration agreement, including, but not limited to, Code of Civil Procedure Sections 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring before the arbitrators a motion for summary judgment or summary adjunction in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure Section 1283.05, however depositions may be taken without prior approval of the neutral arbitrator.

Article 4General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof, is received, the claim, If asserted in a civil action, would be barred by the California statute of limitations, or (2) the claimant falls to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration. 

Article 5Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of signature. It is the intent of this agreement to apply to all medical services rendered any time for any condition.

Article 6Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is Effective as of the date of first medical services.

  •  Patient or Guardian initials

If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. 

I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL SEE ARTICLE 1 OF THIS CONTRACT.

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(Your IP Address :IP:3.235.41.241 )

If Representative,

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