New Patient Online Forms

COVID-19 Pandemic Emergency Dental Treatment

Notice and Acknowledgement of Risk Form

Our goal is to provide a safe environment for our patients and staff, and to advance the safety of our local community. This document provides information we ask you to acknowledge and understand regarding the COVID-19 virus.

The COVID-19 virus is a serious and highly contagious disease. The World Health Organization has classified it as a pandemic. You could contract COVID-19 from a variety of sources. Our practice wants to ensure you are aware of the additional risks of contracting COVID-19 associated with dental care.

The COVID-19 virus has a long incubation period. You or your healthcare providers may have the virus and not show symptoms and yet still be highly contagious. Determining who is infected by COVID-19 is challenging and complicated due to limited availability for virus testing.

Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office.

Dental procedures create water spray which is one way the disease is spread. The ultra-fine nature of the water spray can linger in the air for a long time, allowing for transmission of the COVID-19 virus to those nearby.

You cannot wear a protective mask over your mouth to prevent infection during treatment as your health care providers need access to your mouth to render care. This leaves you vulnerable to COVID-19 transmission while receiving dental treatment.

Pursuant to statements from the Center for Disease Control (CDC) and the American Dental Association (ADA), non­essential or elective treatment, based on the assessment of our staff, will be rescheduled. According to the ADA, dental emergencies are "potentially life threatening and require immediate treatment to stop ongoing tissue bleeding [or to] alleviate severe pain or infection." The ADA also recommends that urgent dental care which "focuses on the management of conditions that require immediate attention to relieve severe pain and/or risk of infection and to alleviate the burden on hospital emergency departments" be provided in as minimally invasive a manner as possible.

I confirm that I have read the Notice above and understand and accept that there is an increased risk of contracting the COVID-19 virus in the dental office or with dental treatment. I further confirm I am seeking treatment for a condition that meets the emergent or urgent criteria noted above. I understand and accept the additional risk of contracting COVID-19 from contact at this office. I also acknowledge that I could contract the COVID-19 virus from outside this office and unrelated to my visit here.

I have read and understand the information stated above:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

COVID-19 PANDEMIC - PATIENT DISCLOSURES

This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID-19 virus.

A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID-19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us.

It is also important that you disclose to this office any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.

I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system. By signing this document, I acknowledge that the answers I have provided above are true and accurate.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Information Form

RESPONSIBLE PARTY

DENTAL INSURANCE INFORMATION

SECONDARY DENTAL INSURANCE INFORMATION

MEDICAL INSURANCE INFORMATION

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

MEDICAL HISTORY FORM

For the following questions, answer yes or no. whichever applies Your answers are for our records only and will be kept confidential.

WOMEN

I have read and understand the above. Any questions I had about this form have been answered and I understand the answers. I understand it is my responsibility to fill out the form correctly and completely.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Acknowledgment of Receipt of Notice of Privacy Practices

7106 Moores Lane
Brentwood, TN 37027
Phone-615-221-0012
Fax-615-221-0016

Purpose: This form is used to obtain acknowledgment of Receipt of our Notice of Privacy Practices or to document our good faith effort to obtain that acknowledgment.

You May Refuse to Sign This Acknowledgement

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

AUTHORIZATION TO RELEASE INFORMATION

Purpose: This form is used to obtain authorization to release information regarding yourself covered under the Privacy Act to people other than yourself.

FOR OFFICE USE ONLY

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Medicare Private Contract

THIS FORM TO BE COMPLETED BY MEDICARE BENEFICIARIES ONLY

A provision in the Social Security Act permits Medicare beneficiaries and physicians to contract privately outside of the Medicare program. A “Private Contract” is a contract between a Medicare beneficiary (Patient) and a physician or other practitioner (Dentist) who has opted out of Medicare. In a private contact, the Medicare beneficiary agrees to give up Medicare payment for services furnished by the Dentist and to pay the Dentist without regard to any limits that would otherwise apply to what the Dentist could charge. Patients and Dentists who take advantage of this provision are not permitted to submit claims or to expect payment for those services from Medicare.

This agreement is between Nashville Oral Surgery (Dr. Mack & Dr. Thomas) with offices located in Nashville and Brentwood, and the Patient indicated above who is a Medicare beneficiary seeking services. The Patient has been informed that the Dentist has opted out of the Medicare Program under §1128, 1156 or 1892 of the Social Security Act effective on the date the physician opted out until the physician cancels this opt-out agreement.

By signing this contract, Patient does the following:

1. Agrees not to submit a Medicare claim (or to request that the Dentist submit a claim) for services or items supplied by Dentist, even if they are otherwise covered under Medicare;
2. Accepts full responsibility for payment of the physician’s or practitioner’s charge for all services furnished by the physician or practitioner, unless any part of the service is covered under a private dental insurance plan;
3. Understands that Medicare limits do not apply to what the physician or practitioner may charge for items or services furnished by the physician or practitioner;
4. Understands that Medicare payment will not be made for any items or services furnished by the physician or practitioner that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim has been submitted;
5. Enters into this contract with the knowledge that he or she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare;
6. Acknowledges that a copy of this contract has been made available to him/her.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.