k g , dds general dentist › cb24fba4 › files...staff helps patients overcome their natural fear...

We are a personal dental practice offering comprehensive services. Our services range from simple fillings to the most sophisticated crown, bridge, and implant restorations. What is different about us is that we provide very personal, quality dental care. We strive to provide the best dentistry we can possibly achieve for children and adults!

Dentistry has dramatically changed over the years. New materials and techniques allow us to perform wonderful transformations! The children who come to our dental practice who have dental sealants placed grow up with negligible decay. For those patients who require “heroic” solutions to their dental problems, we can help! We provide post-cancer reconstruction and trauma resolution. Cosmetically we work true magic through bonding, teeth whitening, and an array of procedures to repair teeth and strengthen self-esteem!

Dr. Gupta graduated from Northwestern University Dental School in 1992. Over the years, she has developed and enjoys strong relationships with her patients. Our professional and friendly staff helps patients overcome their natural fear of going to the dentist.

Due to recent studies, it is proven that the bacteria in the mouth can cause other health conditions and or complications. At our office, we strive to prevent tooth infection and bacterial infections throughout the rest of the body. Studies have now connected the bacteria in the mouth to heart disease, osteoporosis, rheumatoid arthritis, lung infections, pancreatic cancer, and low birth weight babies.

We are the only dental practice at the Elmhurst Hospital Campus! We are located on the third floor of the Center for Health.

We are here to take care of all of your dental needs. You’re going to find a different kind of dentistry here!

Sincerely,

Kavita Gupta, DDS

YOUR SMILE . . . OUR FOCUS!1200 S. York Rd., Suite 3110 Elmhurst, IL 60126

630.782.6999 fax 630.782.6790 www.kavitagupta.com

Kavita Gupta, DDSGeneral DentiSt

Welcome!

We are delighted that you have chosen our office to care for your dental needs.

Having graduated from Northwestern University, I am proud to provide gentle, family oriented dental care to the adults and children of this community. We utilize state of the art equipment and sterilization techniques in a modern medical facility. In addition to general dentistry, we offer treatment in cosmetic and reconstructive dentistry. Our caring staff believes in providing a comfortable atmosphere during treatment. So, please let us know of anything we can do to make your office visit as pleasant as possible.

Enclosed are our new patient information forms that you can complete at your convenience. Please bring them with you and if you have insurance, please bring your insurance ID card. We file with most insurance plans.

Our office is located at York and Roosevelt Road in the Elmhurst Memorial Center for Health. Please call us at (630) 782-6999.

We are happy to have you as a new patient and look forward to meeting you at your scheduled appointment.

Elmhurst Memorial Center for HealthFrom Route 83 (Kingery Hwy)Take Roosevelt Road EastExit at York Road NorthTurn Left on Brush Hill RoadFree valet parking available

POS Reorder # 1623415




About YouPatient Name

What You Prefer to be CalledBirthdate AgeSocial Security #Mailing Address City State Zip

Home Phone #Work Phone #Cell Phone #e-mail AddressPatient Contact Preference9 Text 9 Phone 9 EmailReferred By

EmployerEmployer’s Address

City State Zip

Employer Phone #Occupation

Status: Single Married Divorced Widowed

Spouse’s Name

Do you have children? Yes No How many?

Account InformationPerson responsible for account

NameRelationshipBilling Address City State Zip

Social Security #Drivers License #Work Phone #Home Phone #

Insurance InformationPrimary Dental Insurance Insurance CarrierInsurance Co. Address:Group Plan #Phone #Insured’s NameRelationDate of BirthInsured’s SS#Insured’s EmployerSubscriber ID # Secondary Dental Insurance Insurance CarrierInsurance Co. Address:Group Plan #Phone #Insured’s NameRelationDate of BirthInsured’s SS#Insured’s EmployerSubscriber ID #

In Event of Emergency

Who should we contact?Relationship:Home Phone #Work Phone #Cell Phone #Who is your Medical Dr / Pediatrician / Family Dr?

M.D.’s Phone #

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Today’s Date

Last First M

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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 medicationthat you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Patient Name: Birth Date: Date Created:

Kavita Gupta, DDS Eaglesoft Medical History

Signature of Patient, Parent or Guardian:

X __________________________________________________________________________________________________________________ Date: ________________________

Signature of Doctor:

X __________________________________________________________________________________________________________________ Date: ________________________

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.

Anxiety/Depression GERD HPV

Name of Patient or Personal Representative Signature of Patient or Personal Representative

Date Description of Personal Representative’s Authority

Acknowledgement of Receipt of Statement of Privacy Practices

I acknowledge that I have received a copy of the Statement of Privacy Practices for the office of Elite Smiles. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

Kavita Gupta reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed to me.

ADDITIONAL DISCLOSURE AUTHORITY

In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below.

ANY MEMBER OF MY IMMEDIATE FAMILY YES NO

SPOUSE ONLY YES NO

OTHER (PLEASE SPECIFY): YES NO

OFFICE USE ONLY BELOW THIS LINE

Record of Acknowledgement not obtained

NEEDED MORE TIME TO REVIEW STATEMENT OF PRIVACYPRACTICES.WANTED TO CONSULT WITH ANOTHER PERSON, BEFORE SIGNING.UNABLE TO SIGN.

REASON NOT GIVEN.

OTHER (EXPLAIN):

PROVIDED PRIOR TOTREATMENT?DATE PROVIDED:

REASON FOR DENIAL:

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YES NO




FINANCIAL POLICY

We are committed to providing you with the highest quality dental care utilizing only the best materials and technology available. In our process of doing so, we have formulated a financial policy to continue to provide you with several options to choose from, in order to meet your financial needs.

DENTAL INSURANCE:Our office is happy to cooperate with our patients who are covered by dental insurance. However, it is your responsibility to inform us when your policy changes, so we can bill the correct insurance company. We also ask that you “READ YOUR POLICY THOROUGHLY” so you are fully aware of benefits provided and the limitations imposed. Please call your insurance company if you have any questions concerning your plan. In order to provide you with optimal treatment, each patient is treated according to their individual dental needs; we do not diagnose according to your insurance plans benefits. (Please check with our office to see what insurance plans we are Preferred Providers for).

All incurred charges are ultimately your responsibility, regardless of insurance coverage. Your employer and the insurance company negotiated a contract that “our office” was not involved in. We DO NOT control how your benefits are paid or your contractual limitations. What that means is, if you have a concern over what your insurance pays on a dental procedure due to a contractual limitation or a non-covered procedure, you will need to take the issue up with your insurance company and not our office. We will attempt to do all we can to get your insurance to pay; however, all balances not paid by your insurance company are due by you 20 days after you receive our final statement.

PAYMENT OPTIONS:Thank you for choosing Dr. Kavita Gupta’s dental office. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options. You can choose from:

Cash, Check, Visa, MasterCard, or Discover Card. We offer a 5% courtesy accounting adjustment to patients who pay for their treatment with cash or check prior to completion of care for treatment plans of $1000 or more.

Convenient Monthly Payment Options1 from CareCredit Healthcare Credit Card which allows you to pay over time, with no annual fees or pre-payment penalties.

PLEASE NOTE:Dr. Kavita Gupta requires payment at the beginning of your treatment. If you choose to discontinue care before treatment is complete, your refund will be determined upon review of your case, less any time and materials, plus lab cases.

For plans requiring more than 3 appointments, alternative payment arrangements may be provided. For larger, more comprehensive treatment plans of $1000 or more, a 10% deposit is required to secure your initial treatment appointment.

For patients with dental insurance we are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement for your treatment.2 Patient portion of the bill is due at time of service.

A fee of $50 is charged for patients who miss or cancel an appointment without 48-hour notice.

Dr. Kavita Gupta charges $50 for returned checks.

If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need.

Patient Signature Date

Patient Name (Please Print)POS Reorder # 1623417




Statement of Privacy PracticesOur office is dedicated to protect the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee to ensure that your health information is never compromised is a principal concept of our practice. We may, from time to time, amend our privacy policies and practices but will always inform you of any changes that might affect your rights.

Protecting Your Personal Healthcare Information

We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and Accountability Act and the state of Washington. This includes issues relating to your treatment, payment, and our health care operations. Your personal health information will never be otherwise given to anyone – even family members – without your written consent. You, of course, may give written authorization for us to disclose your information to anyone you choose, for any purpose.

Our offices and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality of your records is always protected. Our privacy policy and practices apply to all former, current, and future patients, so you can be confident that your protected health information will never be improperly disclosed or released.

Collecting Protected Health Information (PHI)

We will only request personal information needed to provide our standard quality of health care, implement payment activities, conduct normal health practice operations, and comply with the law. This may include your name, address, telephone number(s), Social Security Number, employment data, medical history, health records, etc. While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law. Disclosure of your Protected Health Information

As stated above, we may disclose information as required by law. We are obligated to provide information to law enforcement and governmental officials under certain circumstances. We will not use your information for marketing purposes without your written consent. We may use and/or disclose your health information to communicate reminders about appointments including voice mail messages, answering machines, and postcards.

Any breach in the protection of your personal health information, including unauthorized acquisition, access, use, or disclosure, will be fully investigated, addressed, and mitigated as established by the HIPAA Privacy Rule. You have a right to and will be provided all information relating to any breach involving your personal PHI.

Your Rights as our Patient

You have a right to request copies of your healthcare information; to request copies in a variety of formats; and to request a list of instances in which we, or our business associates, have disclosed your protected health information for uses other than stated above. All such requests must be in writing. We may charge you for your copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately. You can also notify the U.S. Department of Health and Human Services.

Please ask if you have any questions about your privacy rights or the protection of your health information.





Our goal is to address all of our patient’s needs and help you look and feel your personal best!

In order to achieve the highest quality care, we encourage you to answer the following:

When I see a picture of myself, the first thing I notice is:

Do you have any concerns regarding past dental experiences?

Are there any other services you desire and think we could assist you with? Yes NoIf yes, please explain

• Are any of the following areas of concern? Please check all that apply 9 Frown lines between brows 9 Fine lines and wrinkles 9 Tired looking skin 9 Significant lines around nose and/or mouth 9 Wrinkles around eyes

• Are there dark areas above current crown or bridge work that concern you? Yes No • Would you like your teeth to be whiter? Yes No • Are any of your teeth yellow, stained or discolored? Yes No • Would you like to change anything about the appearance of your teeth or smile? Yes No

If Patient is a Minor • Is this the child’s first visit to a dentist? Yes No • Does the child snore? Yes No • Does the child grind teeth? Yes No • Are there issues with the tonsils (such as enlarged)? Yes No • Does the child have any habits such as pacifier / thumb / finger sucking? Yes No • Does the child have a bottle or sipper cups or speech issues? Yes No • Do you live in an area without fluoridated water? Yes No • Has the child had any unfavorable dental experiences? Yes No Explain




Patient’s Name

1. Purpose of first visit?

2. Any other problems?

3. Previous dentist name tel

4. How long since last dental visit? 6 months 1 year

What was done at that time? Were dental X-rays taken? Yes No5. When were your teeth last cleaned? 6 months 1 year6. Did you make regular visits? Yes No How often? 6 months 1 year

7. How often do you brush your teeth?8. Do you use dental floss? Yes No How often?9. Have you lost teeth? Yes No If no, go to next question Why? Have they been replaced? Yes No How? How old? Fixed bridge Removable bridge Denture Implant Are you happy with the replacement? Yes No

If no, explain10. Do you clench or grind your teeth? Yes No11. Does your jaw click open or pop? Yes No12. Any pain or soreness in your face muscles around your ear? Yes No13. Frequent headaches, neckaches, or shoulder pains? Yes No14. Does food get caught in your teeth? Yes No15. Are your teeth sensitive? Yes No16. Do your gums bleed or hurt? Yes No17. Are any teeth chipped, loose, tipped, or shifted? Yes No18. Are you unhappy with the appearance of your teeth? Yes No19. Do you have bad breath at times? Yes No20. Have you ever had gum surgery or treatment? Yes No

Explain:21. Have you ever had braces (orthodontic work)? Yes No22. Is there some unpleasant dental experiences or something about dentistry that frightens you? Yes No23. Any problems with prior dental treatments? Yes No

If yes, explain:

I certify that the above information is complete and accurate

Patient or Responsible Party Signature Date

Reviewed by Doctor: DatePOS Reorder # 1623419

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k g , dds general dentist › cb24fba4 › files...staff helps patients overcome their natural fear...

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