Richard J Pfau, DMD
 
We Take The Time To Care!
 
Call Us Now: 503-362-9151
848 Commercial St NE, Salem, OR 97301
 
 
 
 
 
 

New Patients

 

Patient Registration

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient Information
 
 
 
 
 
 
 
 
 
 
 
 
 
Employment Status
 
 
 
 
 
Emergency Contact Information
 
 
 
Primary Insurance Information
 
 
 
 
 
 
 
 
 
 
Secondary Insurance Information
 
 
 
 
 
 
 
 
 
 
 
 
 

Medical Information

Please answer each question. Check yes or no. If in doubt, leave blank.
 
 
 
 
 
 
 
 
 
 
 
 
Are you ALLERGIC, or have you ever experienced any reaction to the following:
 
 
 
Check any of the following of which you have had or have at present:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information, including the diagnosis and the records of any treatment or examination rendered, to my child or me during the period of such Dental care to third party payers and or health practitioners.
 
 
 
 
 
 
 
 
 
 

Financial Policy Acknowledgement

We are committed to providing you with the best possible care. Our fees reflect our professional commitment to excellence. If you have insurance, we are happy to help you receive your maximum allowable benefits. In order to achieve these goals we need your assistance and your understanding of our payment policy. For the convenience of our patients we offer the following methods of payment of fees.

• Payment in full by cash, bank card or alternate financing of each appointment as service is rendered. Alternate financing (payment plans) must be arranged before treatment is rendered.
• For insurance patients, we will accept payment directly from the insurance company only for that percentage the company will cover and do require that the deductible and non-covered fees be paid at each visit.
• Bank charge cards- Visa, MasterCard, and Discover cards are accepted.
• There will be a 5% discount for accounts paid in full on the day of service.
This does not apply to credit card payments since the clinic pays a credit card
user fee.
• Senior citizens (65+) will receive a 5% discount on all services provided. An
additional 5% discount (for a total of 10%) is extended to senior citizens who pay in full on the day of service. The additional 5% does not apply when using a credit card for payments due to credit card user fees charged to the clinic.
• There will be a flat fee of $25 charged for any appointment not cancelled within 24 hour notice of that appointment.

Our office staff understands insurance, and we will be glad to assist you in obtaining the maximum benefits specified in your contract. It is important that you realize, however .. ..


• Your insurance benefit is a contract between you, your employer, and the insurance company. We are not a party to that contract. This office files your insurance claim as a courtesy to you.
• Our fees generally, but not necessarily, fall within the usual and customary fee structure determined by your carrier.
• Not all services are a covered benefit in all contracts.
• You (not the insurance company) are responsible to us for all fees for services rendered to you.
• Upon request, a pre-determined estimate of benefits can be given to you.
• We will gladly discuss your proposed treatment and answer any questions you might have as to the involvement of your benefit program in receiving this care. We appreciate the opportunity to serve you.

THERE IS NO INTEREST OR FINANCE CHARGE ON CURRENT ACCOUNTS.
After 90 days, all accounts are subject to a Finance Charge of 1.5% per month, which is 18% per annum, with a minimum charge of $1.00.

I acknowledge that I am financially responsible for all charges. If it becomes necessary to effect collections of any amount owed on this or subsequent visits, the undersigned agrees to pay for all costs and expenses,including reasonable attorney fees. I hereby authorize the doctor to release information necessary to secure payment.
(Please check the box below)
 
 
 
 
 
 

Consent For Use & Disclosure of Personal Health Information (HIPAA)

This form authorizes us to use and disclose your protected health information (PHI) for the purposes of healthcare operation, treatment and payment activities. Before signing, please read our Notice of Privacy Policies to gain a clear understanding of how we may use and disclose your PHI. For questions concerning our Notice of Privacy Policies, please contact our Office Manager at (503) 362-9151.

Patient's Consent
 
 
 
 
 
 
I have read your Notice of Privacy Policies and I consent to your use of my PHI for the purposes of healthcare operations, treatment and payment activities.

If this consent is signed by a personal representative (parent/relative) on behalf of the patient, please complete the following:
 
 
By checking this box, you agree to the Consent above. For any questions, please see our Office Manager.