Mid-cities Dental Management, Inc.

“Dental Care Anywhere”

Dental Referral Information

Date: ______Facility: ______

Resident: ______Room: ______

Primary Complaint: ______

Does patient have any existing teeth? □YES □NO

Is patient on HOSPICE? □YES □NO

How long has the resident been in the facility? ______

if less than 1 year please specify: □Long Term □Short Term

patient dental care information verification

1. Who is the medical responsible party for the resident? ______

2. Who is the financial responsible party for the resident? ______

3. Who handles financial funds for the resident? Resident Facility RP

4. Is resident’s account presently in good standing with the facility? Yes No

5. Payment: NURSING HOME MEDICAID MEDICAID PENDING

FACILITY PAY (FULL VENDOR/$0 AI) PRIVATE PAY

6. Please verify the resident’s applied income amount: $______

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BUSINESS OFFICE MANAGER DATE

PATIENT AUTHORIZATION

(Please Read Carefully)

1. I authorize the release of any and all information including medical and financial history to Mid-cities Dental Management Inc. for the purpose of dental services.

2. I authorize payment of dental funding from Medicaid, or third party payers otherwise payable to me, to be PAID DIRECTLY TO Mid-cities Dental Management Inc. for dental services rendered.

In accordance with HIPAA all your dental records will be the property of Mid-cities Dental Management and available to you at any point in time upon authorized request.

HIPAA - Purpose of Privacy Practices: By signing this form you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations.

Notice of Privacy Practices: You have the right to read the Notice of Privacy Practice before you decide whether to sign this consent. The notice provides a description of the treatment, payment activities and healthcare operations of the use and disclosures we may make of your protected health information and of other important matters about your protected health information.

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RESPONSIBLE PARTY DATE

Mary Ellis, New Patient Coordinator 717 Lingco Drive, Ste. 202 Ph: 972-497-9200

Richardson, TX 75081 Fax: 972-497-9201