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  • Patient Registration

  • About Your Spouse or Guardian

  • Primary Dental Insurance

  • Secondary Dental Insurance

  • Medical History

  • For the following questions, please check ALL that apply.
    THESE FACTS HAVE A DIRECT BEARING ON YOUR DENTAL HEALTH.
  • General Medical History:

  • Cardiovascular System

  • Central Nervous System

  • Respitory System

  • Digestive System

  • Endocrine System

  • Hemotogenic System

  • Allergies

  • Genitourinary System

  • Bones & Joints

  • Other

  • For Women

  • Dental History

  • Please list any type of medication you are presently taking as well as the dosage.
    Name/Type of DrugDosageHow many times per day 
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  • General Dental Responsibility and Consent Statement

    I also give my consent to ANY advisable and necessary dental procedures, medications or anesthetics to be administered by the attending dentist or his supervised staff for diagnostic purposes of dental treatment. These records may include study models, photographs, x-rays and blood studies. I understand and acknowledge that I am financially responsible for the services provided for myself and or the above named, regardless of insurance coverage. Treatment plans involving extended credit circumstances are subject to a credit check. I also understand that the treatment plan presented to me is only an estimate. Occasionally, the need may arise to modify treatment. In such a case, I will be informed of the need for additional treatment, and any fee modification. To the best of my knowledge the information in this form is accurate.

  • Signature of Patient or Guardian

  • Signature of Witness

  • Signature of Doctor

  • Appointment Commitment Policy

    As your time is valuable, we want to assure you that you will be seen on time for your appointment. Likewise, we would appreciate a 24 hours notice should you every have to change an appointment, so that another patient in need may receive care. We will make every effort to make your visit as pleasant and comfortable as possible.

  • Photography Release

    I authorize the use of my radiographs and/or photographs for use in seminars or publication of Dr. Del Kovacevic.

    Signature of Patient of Guardian of minor

  • FINANCIAL POLICY


    In order to provide you with the highest quality dental care available, we provide our patients with estimates of dental treatment and fees. Patient, parent and/or guardian are responsible for the patient portion at the time of service. Financial options that we provide at this time:

    • Cash or check
    • Major credit card (Visa, Master Card, Discover)
    • Extended Payment Options (Care Credit – based on credit approval)
    Regarding Dental Insurance: Dr. Kovacevic and staff realize how important dental insurance benefits are to our patients. It is the responsibility of the patient to keep us informed of changes in insurance carriers, and to provide copies of insurance cards. We ask that you carefully review your policy so you are aware of benefits, deductibles, frequencies, and limitations or restrictions. Dental insurance is a contract between you and your insurance company; our role is to assist with filing claims and collection of payments. Ultimately, all dental services are charged directly to you, the patient, and you are personally responsible for payment of all dental services, within sixty days of your visit, regardless of insurance coverage. Please be aware that your insurance plan may have a yearly allowance (maximum) and charges exceeding that amount will be your responsibility. Also, should you have coverage from two insurance plans, please note that not all secondary policies will cover remaining portions.For a more accurate treatment estimate, we will be glad to pre-determine any treatment you may need, but it may take 4-6 weeks. Please do not allow your insurance to dictate the level of treatment you receive. Your dentist is here to provide the highest quality of care for you and/or your family regardless of insurance. You should receive an Explanation of Benefits the same time our office receives payment. Please be advised that it may be necessary to re-submit claims for payment, and occasionally, for various reasons, claims may be rejected. We will do our best to obtain payment for you, but we cannot render services based on the assumption that insurance will cover all claims, at all times. If any dental services have been provided by any other dental provider within the existing benefit year, please let us know. For Out-of-Network Insurance Plans, options are:
    • Pre-Determination of treatment – to obtain accurate policy allowances and co-pays.
    • Payment may be paid in full at the time of service, and a refund given once insurance payment has been received.
    • A credit card may be left on file. Once the insurance payment is received, the remaining balance will be applied to the credit card
    • Care Credit – no interest payment plan
    Estimated co-pays and deductibles are due at the time of service. For multiple appointment procedures, such as major restorations (onlays, crowns, veneers), and prosthetics (implants, partials, dentures), final payment is expected prior to the final insert appointment.

    I HAVE READ AND ACCEPT THE TERMS AND CONDITIONS OF THIS AGREEMENT.
    I AUTHORIZE MY INSURANCE COMPANY TO PAY MY DENTAL BENEFITS DIRECTLY TO THIS OFFICE.

  • Dr. Del Kovacevic

    700 Pellis Rd.
    Greensburg, PA 15601
    (724)836-2433
    del.kovacevic@att.net


    CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

    PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

    Purpose of consent: By signing this form, I consent to the use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.
    Notice of Privacy Practices: I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
    I have been informed of and given the right to review and secure a copy of your Notice of Privacy Practices which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

    I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

    Right to Revoke: I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected. I understand that you may decline to treat me, or continue treatment, if I revoke this consent.

    You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice at any time by contacting the office.


    Signature:
    I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and health care operations.

  • This field is for validation purposes and should be left unchanged.