New Dental Application

Instructions

GHC Dental - New Patient Application

Please select your GHC Dental Office:

Patient Information

Patient Information Section

First Name

Middle Initial

Last Name

Social Security Number

Numbers only (example 123456789)

Address

City

State

Zip

Home Phone

Cell Phone

If you do not have a cell phone, please enter: 000-000-0000

Date of Birth

Age

Yes! Sign me up for Genesis email updates

Consent to Call

Consent to Text

Gender

Insured's Language

(Insured's Language) Other

Marital Status

Race

(Race) Other

Ethnicity

(Ethnicity) Other

Veteran Status

Homeless Status

Student

Agricultural Status

Public Housing

If (student) yes, Provide School Name

Current Primary Care

Date of your last dental exam

Date of last dental x-rays

Current Primary Care Provider

City

Current Primary Care Provider

State

Current Primary Care Provider

Phone

Current Primary Care Provider

Current Pharmacy

City

Current Pharmacy

Phone

Current Pharmacy

Provider Preference

Do you have a provider preference?

Requested Provider

Emergency Contact (ages 19 and above):

Name

Emergency Contact

Phone

Emergency Contact

Relationship

Emergency Contact

How did you hear about Genesis Healthcare?

How did you hear about Genesis Healthcare? Please select one

Referral Source

If you selected 'Referral' for how you heard about Genesis Healthcare, please specify the referral source

Interest in Serving on Board of Directors

Are you interested in serving on the Board of Directors for Genesis Healthcare?

Dental Insurance

Primary Dental Insurance

Insured’s Name (If other than patient)

Primary Insurance

Insurance Company

Primary Insurance

Address

Primary Insurance

SSN

Primary Insurance

DOB

Primary Insurance

Employer

Primary Insurance

Secondary Dental Insurance

Insured’s Name (If other than patient)

Secondary Insurance

Insurance Company

Secondary Insurance

Address

Secondary Insurance

SSN

Secondary Insurance

DOB

Secondary Insurance

Employer

Medicare

Medicare Patients-Livetime Authorization to Permit Payment of Medicare Benefits to Provider, Physicians, and Patient

I certify that the information given to me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Health Care Financing Administration, or its intermediaries or carriers any information needed for this or related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for covered Medicare services to the physician. As my healthcare provider, I appoint Genesis Healthcare, Inc1 to act as my representative in connection with any claim or asserted right under Title XVIII of the Social Security Act and related provisions of Title XI of the Act and authorize Genesis Healthcare, Inc make any claims, present or elicit evidence, obtain appeals information, and receive notice in connection with my claim, appeal, grievance. I further authorize Genesis Healthcare, Inc to release any and all medical and billing information to any health care provider involved in my treatment and to any health care facility directly or indirectly involved in my treatment for purposes including, but not limited to, billing, collection, quality assurance or risk management activities, or defense of litigation or anticipated litigation and to any insurance company, health maintenance organization or other entity which is directly or indirectly responsible for payment or review of services provided by Genesis Healthcare, Inc.

Patient/Patient Authorized Representative Signature (Sign below with your mouse or finger):

Patient Name (Print)

Relationship to Patient if Unable to Sign

1

Financial

Financial Statement

I understand and agree that regardless of my insurance coverage, I am ultimately responsible for payment of any charges for professional services rendered. I understand that I will be ultimately responsible for collection fees and any attorney fees should my account be placed with a collection agency due to nonpayment of my account. I certify that the information I have given is true and correct to the best of my knowledge. If I have health insurance, Genesis Healthcare, Inc. will file on my behalf, but it is my responsibility to see that my health insurance policy pays the benefits provided under said policy. If there is a change in family member status, it is my responsibility to give the information, in writing, to Genesis Healthcare, Inc. as I am responsible for all charges incurred for my family members. I request that payment for professional service rendered be made directly to Genesis Healthcare, Inc. I permit a copy to be used in place of the original.

Patient/Patient Authorized Representative Signature (Sign below with your mouse or finger):

Patient’s Name (Print)

Relationship to Patient if Unable to Sign

Minor

Minor Patients Only (0-18 years)

If the patient is a minor, please complete the Minor Patient section. If the patient is NOT a minor, please proceed to the next section "History".

Is the patient a minor (0-18 years)?

Mother (if the address and phone numbers are the same as the patient, please indicate same.)

Full Name

Mother

Phone

Mother

Address

Mother

City

Mother

State

Mother

Zip

Mother

Employer

Mother

Employer Phone

Mother

Father (if the address and phone numbers are the same as the patient, please indicate same.)

Full Name

Father

Phone

Father

Address

Father

City

Father

State

Father

Zip

Father

Employer

Father

Employer Phone

Father

Alternate Caregiver | Please list any caregivers that you authorize to obtain medical care for your child in your absence

1st Alternate Caregiver Name

1st Alternate Caregiver Relationship to Minor

1st Alternate Caregiver Phone Number

2nd Alternate Caregiver Name

2nd Alternate Caregiver Relationship to Minor

2nd Alternate Caregiver Phone Number

3rd Alternate Caregiver Name

3rd Alternate Caregiver Relationship to Minor

3rd Alternate Caregiver Phone Number

Emergency Contact

Emergency Contact other than caregiver

Phone

Emergency Contact other than caregiver

Relationship

Emergency Contact other than caregiver

Parent/Legal Guardian

With my permission, I hereby authorize the above individuals to consent to all medical care and attention which is deemed necessary and appropriate by a health care provider at Genesis Healthcare, Inc for this minor. This includes, but is not limited to emergency services, lab tests, procedures, and immunizations. The listed individuals are given authority to discuss and change appointments, financial or insurance details, and clinical information including labs/tests.

Parent/Legal Guardian Signature (Sign below with your mouse or finger):

Parent/Legal Guardian Name (Print)

Siblings | List all siblings at this practice

1. Full Name

Sibling

1. DOB

Sibling

1. Age

Sibling

2. Full Name

Sibling

2. DOB

Sibling

2. Age

Sibling

3. Full Name

Sibling

3. DOB

Sibling

3. Age

Sibling

4. Full Name

Sibling

4. DOB

Sibling

4. Age

Sibling

History Intake

Dental History

Do your gums bleed when you brush or floss?

Are you experiencing any dental pain or discomfort?

Are your teeth sensitive to cold, hot, sweets, or pressure?

Do you grind your teeth?

Is your mouth dry?

Do you have sores or ulcers in your mouth?

Have you had any periodontal (gum) treatments?

Do you wear dentures or partials?

Have you had orthodontic (braces) treatment?

Have you had injury to your head or mouth?

Have you had any problems with previous dental treatment?

Do you have any clicking, popping, or discomfort in your jaw?

Do you have earaches or neck pains?

Do you use tobacco (smoking, snuff, chew)

Do you have an artificial heart valve?

Have you had a heart infection (endocarditis)?

Have you ever had a heart attack (myocardial infarction)?

Other

How do you feel about your smile?

Medical History

Anemia

Gout

Osteoporosis

Anxiety

Heartburn

Prostate problems

Arthritis

Heart Problems

Seasonal Allergies

Asthma

High Blood Pressure

Seizures

Autoimmune Disease

High Cholesterol

Skin Problems

Back Problems

Infections (HIV, TB, etc)

Sleep Problems/Apnea

Bone Problems

Kidney Problems

Stomach/Intestine problems

Clotting Disorder

Lung Problems

Stroke

Dementia

Migraines

Substance use

Diabetes

Mental Disorders

Thyroid Disease

Fibromyalgia

Nerve/Muscle Disease

Other

Medication & Allergy History

1. Medication

1. Allergy

2. Medication

2. Allergy

3. Medication

3. Allergy

4. Medication

4. Allergy

5. Medication

5. Allergy

6. Medication

6. Allergy

7. Medication

7. Allergy

8. Medication

8. Allergy

9. Medication

9. Allergy

Surgical & Hospital History

1. (Surgery) Where

1. (Surgery) When

1. (Hospital Stay) Where

1. (Hospital Stay) When

2. (Surgery) Where

2. (Surgery) When

2. (Hospital Stay) Where

2. (Hospital Stay) When

3. (Surgery) Where

3. (Surgery) When

3. (Hospital Stay) Where

3. (Hospital Stay) When

4. (Surgery) Where

4. (Surgery) When

4. (Hospital Stay) Where

4. (Hospital Stay) When

5. (Surgery) Where

5. (Surgery) When

5. (Hospital Stay) Where

5. (Hospital Stay) When

Narcotic

Narcotic Acknowledgment

I (Print Name) acknowledge that it has been explained to me that Genesis Healthcare, Inc. does not provide chronic narcotic pain management. This includes the use of narcotic medication as well as other supplemental controlled substances. I understand and agree that I will be referred to another clinic for pain management by that facility’s physician.

Patient Signature/Patient Authorized Representative (Sign below with your mouse or finger):

Print Name

Relationship to Patient if patient unable to sign.

Voicemail

Answering Machine/Voice Mail Messages

There may be times when our office is not able to reach you by telephone. With your permission, we would like to be able to leave messages on your home answering machine/cell phone voice mail. To comply with strict legal standards, a written release will allow us to leave a message on your answering machine. By signing below, you are authorizing us to leave messages on your answering machine at the telephone number you have given us in your record.

Patient/Patient Authorized Representative Signature (Sign below with your mouse or finger):

Patient Name (Print)

Relationship to patient if Unable to Sign

HIPAA

HIPAA Authorization for Release of Medical Information

Some patients prefer other individuals, especially family members, be allowed access to their medical information. To comply with strict legal standards, a written release is required to allow another person access to your medical records. This release grants permission to individual(s) listed below to: Make or confirm appointments, have access to x-ray and laboratory findings, pick up sample medications, be made aware of your diagnosis, prognosis, and treatment plans, and serve as your emergency contact. This permission applies to telephone and answering machine messages as well as other means of communication.

Patient’s Signature (Sign below with your mouse or finger):

Patient Print

1. Designated Party:

Telephone

Relationship

Consent

Consent for Treatment and Authorization

I, the undersigned, do hereby authorize and consent to dental examinations, x-rays, blood tests/laboratory procedures, invasive or surgical procedures, and other medically appropriate services under the general or specific supervision of any member of the medical staff of Genesis Healthcare, Inc for the patient named on this form. It is understood that this authorization is given in advance of any specified diagnosis, treatment or care being required but it is given to provide authority and power to render care by providers of Genesis Healthcare, Inc. in the exercise of her/his best judgment that they may deem advisable. I understand that state law requires physicians to report certain communicable diseases to the Health Department. SC Code Ann. Sec 44-29-10. Regulation 61-20. I agree that if I leave a physician’s office against the advice of my physician(s) of Genesis Healthcare, Inc and its personnel, they are released from responsibility or liability for any injuries or damage which may result from leaving against medical advice. I authorize a physician of Genesis Healthcare, Inc to test me for HIV antibodies or tuberculosis when the doctor or any employees are exposed to body fluids in a manner which may transmit human immunodeficiency virus (HIV), or infection of tuberculosis. In the event of such an exposure, you will be deemed to have consented to such testing, and to have consented to the release of the test results to the person(s) who may have been exposed.

Patient/Patient Authorized Representative Signature (Sign below with your mouse or finger):

Patient Name (Print)

Relationships to Patient if Unable to Sign

IMPORTANT

Important Patient Information

NOTICE

I have received GHC’s Notice of Privacy Practices and agree to the terms regarding the use and disclosure of medical information.

Patient/Patient Authorized Representative Signature (Sign below with your mouse or finger):

Patient Name (Print)

Relationship to Patient if Unable to Sign

Authorization for Release

Authorization for Release of Medical Records

Please Fax Records to Attention

I authorize the use and disclosure of my individual health information as described below. I understand that the information I authorize a person or entity to receive may be re-disclosed and no longer protected by federal privacy regulations. (Note: S.C. Law prohibits the redisclosure of mental health records).

Patient’s Name

DOB

Social Security #

MR#

Person/Organization disclosing the information:

Person/Organization receiving the information (Select all that apply):

Pee Dee Health Care

201 Cashua St Darlington, SC 29532 Phone: 843.393.7452 Fax: 843.393.6210

Genesis Healthcare, Darlington (Behavioral Health)

115 Exchange St. Darlington, SC 29532 843.393.9421 843.968.3473

Olanta Family Care

211 S Jones Rd Olanta, SC 29114 843.396.9730 843.396.9735

Lamar Family Care

301 W Main St. Lamar, SC 29069 843.395.8400 843.395.8401

Genesis Healthcare Florence OB/GYN

1523 Heritage Ln. Florence, SC 29505 843.673.9992 843.968.3466

Genesis Healthcare Florence Family Medicine and Urology

1523 Heritage Ln. Florence, SC 29505 843.673.0900 843.968.3479

Lowcountry Pediatrics

99 Bridgetown Rd. Goose Creek, SC 29445 843.572.3300 833.771.2207

Walterboro Family Care & Pediatrics

830 Robertson Blvd. Walterboro, SC 29488 843.781.7428 843.781.7429

Walterboro Family Care & Pediatrics Dental

830 Robertson Blvd. Walterboro, SC 29488 843.584.4311 843.584.4312

Walterboro Family Care Endocrinology

830 Robertson Blvd. Walterboro, SC 29488 843.538.8585 843.538.4777

Information for treatment period:

From (Date):

To (Date):

Type(s):

Office Notes

Hospital Notes

Laboratory Test

Consults

Radiology Reports

Ancillary Testing Reports

Other

Other (please specify)

Purpose(s):

Insurance

Legal Investigation

Disability Evaluation

Continued Care

Other:

OR

I may request my information be released to me to exercise my right to access and obtain a copy of my PHI.

I have read and understand this Authorization. I certify that I am the Patient listed above or a person authorized to permit release of records on the Patient's behalf. I hereby release Genesis Healthcare, Inc from any liability or damages arising in connection with or related to the use and/or disclosure of my protected health information pursuant to this Authorization.

Patient Signature (Sign below with your mouse or finger):

Patient Name – Print

Authorized Representative

Relationship to Patient

Telephone Number

Attestation

Patient Financial Self-Attestation Agreement/Acknowledgement

If my application is approved, I request all my medications be filled by a GHC pharmacy.

I have the freedom to have my prescriptions filled at any pharmacy and voluntarily choose to use the services of Professional Pharmacy and understand that I can choose another pharmacy whenever I wish by notifying GHC in writing.

I acknowledge that I have the freedom of choice to request brand-named medications as my preferred medication, when available, pursuant to South Carolina Law and I request that my prescriptions be filled using brand name drugs when available. This statement and request remain in full force and effect until I request otherwise, in writing.

I acknowledge that GHC may obtain Prior Authorizations for brand name medications as authorized by me in this document.

I agree and request that GHC process all manufacturer coupons on my behalf.

I authorize GHC to deliver or mail my prescriptions to me in the event I am unable to pick them up;

I agree to take all medication as prescribed and will notify GHC immediately in the event I am unable to follow prescribed medication instructions.

That any self-referral to a non-GHC provider be added to my GHC medical record and the provider to my GHC care team, so that the responsibility of care remains with GHC.

I will actively participate in any programs prescribed by my physicians such as Case Management, Disease Management, Preventive Care, wellness programs, and other such programs and/or services; and

I certify under penalty of law based on information and beliefs formed after reasonable inquiry, the statements contained in this document are accurate and complete.

I attest that the above information provided to GHC is true and accurate.

Patient/Patient Authorized Representative Signature (Sign below with your mouse or finger):

Patient Name (Print)

Relationship to Patient if Unable to Sign