Name (Signature)

2. Notice of Deemed Consent to HIV Blood Testing

Should an employee be exposed to my blood/body fluid in a way that might allow transmission of infection due to blood borne disease (eg. HIV, Hepatitis, etc) or other communicable diseases; I understand that according to VIRGINIA STATE LAW for the safety, health and possible treatment of our employee, samples of my blood or body fluid may be tested for evidence of infection. I also understand that NEW RIVER VALLEY DENTAL employees and dentist are obligated to submit to blood tests for certain infectious diseases (eg. HIV, Hepatitis, etc.) if I am inadvertently exposed to their blood or body fluid during the course of my treatment in the office.

I have read and understand the above statement.

Name (Signature)
Date

3. ViziLite Oral Cancer Screening Consent

In continuing efforts to provide the most advanced technology and highest quality care available to our patients, this practice is proud to announce the inclusion of the ViziLite Plus exam as an integral part of our annual comprehensive oral cancer screening program.

One person dies every hour from oral cancer in the United States-and the mortality has remained unchanged for more than 40 years. Alarmingly, more than 25% of oral cancer victims have no lifestyle risk factors. Clinical studies have determined that using ViziLite after the standard oral cancer examination improves the clinicianÕs ability to identify, evaluate and monitor suspicious areas at their earliest stages. Early detection of pre-cancerous tissue can minimize or eliminate the potentially disfiguring effects of oral cancer and possibly save your life. Proven screening techniques such as mammogram, Pap smears, PSA and colonoscopy offer the same types of early detection of cancer. ViziLite Plus is an easy and painless examination that gives this practice the best chance to find any oral abnormalities you may have at the earliest possible stage. This technology is the only medical device cleared by the FDA for the identification and monitoring of oral abnormalities that could lead to cancer.

Oral cancer risk by patient profile:
Highest risk: Patients age 40 and older and lifestyle risk factors (tobacco use); patients with a history of oral cancer
High risk: Patients age 40 and older; tobacco users of any age
Increased risk: Patients age 18-39

Dental insurance might not cover this advanced oral cancer screening as an addition to the standard visual examination. This practice prescribes the ViziLite Plus exam for all patients at increased risk but especially
those at high risk and highest risk for oral cancer. With your consent, we will be performing the ViziLite Plus exam following the standard oral cancer examination of the oral cavity for a fee of $65.00.

Patient Name (signature)

4. Information on Patient Rights under HIPAA

This Notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Effective Date: April 2003. Read the notice online (it will open in a new window) or view/print the notice (you will need the free Adobe Acrobat Reader to print this notice).

I acknowledge that I have read and understood this Notice.

Agree Disagree

Patient Name (signature)
Date

I hereby give my permission to the person(s) listed below to authorize treatment and to receive information about the care of the above named patient.

Please list anyone we may share information with:

5. NRV Dental Practice Policies

We provide the very best dental care possible.  Our only purpose is to help you keep your teeth and gums healthy and attractive for your entire life.  One of the ways we accomplish this is to eliminate potential problems, which take away from the quality of our work.  Therefore, we have developed the following policies:

1. Whether you have dental insurance or not, we ask that you pay your portion of the fee on the day the treatment is rendered.  We accept cash, checks, VISA/MasterCard, and Discover.  We also have extended financing plans available for qualified patients who need or want extensive treatment.   Whether you have dental insurance or not, you have final responsibility for our treatment fees being paid.
2. When you schedule an appointment with us, we consider that you have committed to the treatment.  Therefore, we ask that you take your dental appointments seriously and consider them as important and valuable to yourself as we do.  Please do not make an appointment with the idea that you “can always cancel it or not show up if something comes up.”
3. If you absolutely must cancel a reserved appointment, we ask that you give us at least 48 hours notice.  Because we have had a huge problem with people not showing up for an appointment or canceling at the last minute, we now charge $40 per broken appointment without 48 hours notice .  We do not do this to punish people; we do it because we consider that a dental appointment with us is important to your dental health, and we want you to honor your commitments.  We have many people who are trying to get appointments with us.  When someone breaks an appointment with insufficient notice, we cannot fill that time with someone else who wants an appointment.
4. We understand that genuine emergencies do come up.  For a true emergency at the last minute, call us and let us know what is happening.  The solution to all problems is communication.  If something occurs which affects your treatment, financial obligations or appointments with us, call us.  We will bend over backwards and sideways to help people as long as they communicate straight and honestly with us.
5. For people with dental insurance:
• As a free service to our patients, we will bill your insurance company for your treatments.  We collect the insurance portion of the dental fees directly form the insurance company.  However, we must first verify your coverage before we can accept insurance assignment.
• The insurance policy is a contract between the patient and the insurance carrier, NOT between the doctor and insurance company.  The insurance company legally MUST answer to the patient.  The insurance company is under no legal obligation to respond to us.  Therefore, we must turn over to the patient any claim that goes unpaid after 60 days.  The patient must pay the bill at that time, and we will still help you collect from the insurance company.  This is our policy because of the manner in which insurance companies operate.
• Service charges:  By clicking “I agree” below, you agree to pay a service charge of 1.5% per month, or 18% per annum on any unpaid balance on your account which exceeds 30 days.  In the event that your account becomes delinquent, you agree to pay for all collection costs, including attorney.

Please press the button below to submit all the above agreements