Benevolence Health Centers

(323) 732-0100

info@bhchealth.org

Gender Identity: Female
Male
Transgender (M to F)
Transgender (F to M)
Other
Will not disclose

Sexual Orientation: Straight
Gay/Lesbian
Bisexual
Something else
Do not know
Will not disclose

Marital Status: Married
Single
Divorced
Separated
Widowed
Life Partner

Race: American Indian or Alaskan
Native Asian
Black or African American
Native Hawaiian or other
Pacific Islander
White
Other

Ethnicity: Hispanic
Non-Hispanic

Preferred method of contact : Mail
Home Phone
Cell Phone
Email

Preferred Language : English
Spanish
Other

No Social Security #

Name of Previous Primary Care Provider :

Previous Primary Care Provider # :

Relationship to Patient:

1.Primary Insurance/Health Plan Name:

Relationship to patient:

2.Secondary Insurance:

Relationship to patient:

Do you have an Advanced Directive? YES/ NO if YES, must provide a copy Yes
No

Would you like information regarding Advanced Directives? YES/ NO Yes
No

Decline to Share Information Below

Last Level of Education:

Public Housing/Shelter: Yes
No

I do not take any medications

Do you require Interpretive Services? (YES/ NO) Yes No

I (print name of patient)

do hereby consent to and authorize theperformance of all medical and/or dental testing, treatments, and/or surgeries, deemed advisable by the physiciansand/or staff of the Benevolence Health Centers (BHC) to me or to the above-named minor of whom I am the parentor legal guardian. I hereby certify that, to the best of my knowledge, all statements contained hereon are true. Iunderstand that I am directly responsible for all charges incurred for medical and/or dental services for myself andmy dependents regardless of insurance coverage, excluding only authorized services provided under a validprepaid HMO contract. I furthermore agree to pay legal interest, collection expenses, and attorneys' fees incurred tocollect any amount I may owe. I also hereby authorize Benevolence Health Centers (BHC) to release informationrequested by insurance company and/or its representatives. I fully understand this agreement and consent willcontinue until cancelled by me in writing.

Signature of Patient/Responsible Party/Parent of Minor (Electronic Signature):

Printed Name of Patient/Responsible Party:

Relationship to Patient:

I (print name of patient)

hereby assign all medical, dental and/or surgicalbenefits to include major medical and/or dental benefits to which I am entitled, private insurance, and any otherhealth plan to the physician and/or facility on record. I understand that my dental insurance carrier may pay lessthan the actual dental bill of services; I agree to be responsible for payment of all services rendered in my behalf ormy dependents. A photocopy of this assignment is to be considered as valid as the original. I understand that I amfinancially responsible for ALL charges whether or not paid by my insurance. I hereby authorize said assigneeand/or Benevolence Health Centers (BHC) to release all information necessary to secure payment.

Signature of Patient/Responsible Party/Parent of Minor (Electronic Signature):

Printed Name of Patient/Responsible Party:

Relationship to Patient:

HIPPA Privacy Rule of Patient Authorization Agreement :

Authorization for the Disclosure of Protected Health Information for Treatment, Payment, and Healthcare Operations(164.508(a))

I (print patients name)

understand that as part of my health, Benevolence Health Centersoriginates and maintains health record describing my health history, symptoms, examination, test results, diagnosis,treatment, and any plans for future care of treatment.I understand that this information serves as

A basis for planning my care and treatment

A means of communication among the health professionals who may contribute to my health care.

A secure means of applying my diagnosis and surgical information to my bill.

A means by which a third-party payer can verify that services billed were actually provided.

A tool for routine health care operations such as assessing the quality and reviewing the competence of healthcare professionals.

I may request a copy of the Notice of Privacy Practices that provides a more complete description of the information usesand disclosures

I understand that as part of my care and treatment, it may be necessary to provide my Protected Health Information toanother covered entity. I have the right to review Benevolence Health Centers notice prior to signing this authorization. Iauthorize the disclosure of my Protected Health information as specified below for the purposes and to the partiesdesignated by me.

Privacy Rule of Patient Consent Agreement :

Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations(164.506 (a))

I understand that

I have the right to review Benevolence Health Centers Notice of Information practices prior to signing this consent

Benevolence Health Center reserve the right to change the notice and practices and that prior to implementationwill mail copy of any revised notices to the address I have provided, if I have requested.

I have the right to object to the use of my Protected Health Information for directory purpose

I have the right to request restrictions as to how my Protected Health Information may be used or disclosed to carryout treatment, payment, or healthcare operations and that Benevolence Health Centers is not required by law toagree to the restrictions requested.

A tool for routine health care operations such as assessing the quality and reviewing the competence of healthcare professionals.

Signature of Patient or Legal Representative Witness:

Printed Name of Patient or Legal Representative Witness:

Are you interested in any of following dental appointment: Examination
Emergency Consult None

Are you happy with the appearance of your teeth? Yes
No

Do you get dental examinations routinely? Yes
No

Last dental exam date :

Name & phone number of the previous dentist (optional) :

Do you think you have an active decay or gum disease? Yes
No

Do you brush and floss frequently? Discuss Yes
No

Do your gums ever bleed? Yes
No

Do you have clicking, popping or discomfort in the jaw joint? Yes
No

Do you grind your teeth? Yes
No

Have your past experience in dental office always been positive? Yes
No

Do you want to talk to the dentist privately? Yes
No

Are you under a Physician's care? Yes
No

Name of your Physician :

What are you being treated for:

I (print patient name),
acknowledge that I was provided with acopy of the Dental Materials Fact Sheet on written date below.

Patient printed name:

Legal Guardian/Parent of minor printed name:

Legal Guardia/Parent Signature:

Upload Required Documents : Picture ID (PDF, JPEG, PNG) [Max size allow 5MB]

Insurance card front (PDF, JPEG, PNG) [Max size allow 5MB]
Insurance card back (PDF, JPEG, PNG) [Max size allow 5MB]
Other Pertinent Documents (if needed) (PDF, JPEG, PNG) [Max size allow 5MB]

Type the character you see on the image (CasE SeNsiTiVe)

By clicking Submit below, I have reviewed all the fields in detail.

NEW PATIENT REGISTRATION FORM

Patient Registration/Demographic Update

Responsible Party (Guarantor/Parent of Minor is a minor)

Emergency Contact (for minor, Must be Parent or Legal Guardian with paperwork)

Insurance Information

Advanced Directive

Social History

Medications – List all medications you take, prescription and non-prescription, and the dosage

Pharmacy Information

Interpretive Service Needs

CONSENT FOR TREATMENT

ASSIGNMENT OF BENEFITS:

Dental History and Information :

Patients Acknowledgement of Receipt of Dental Materials Sheet