PATIENT HISTORY UPDATE

Uploading your Insurance Card (is mandatory).

If you forgot to bring your dental insurance card. Ask our receptionist for assistance.

Carry Your Insurance Card

Your insurance card is essential. When you check in with the dental office reception, you will likely be asked for your dental insurance card. If you forget to carry your dental insurance card:

You can access your dental insurance card and coverage information by calling or electronically by logging in online. And get a copy/screenshot of your insurance card.

Inform the dentist receptionist immediately as soon as you check in. They will allow you to email your insurance card copy to yourdentistforms@gmail.com for your dentist to bill your dental insurance.

Why do you need a dental insurance ID card when you visit your dentist?

It is recommended. Your ID card tells your dentist the plan you're enrolled in to ensure you're charged the correct co-payment. They were significantly needed if your employer changed your dental insurance plan since your last visit.

In case your dental insurance denies your dental claim. You or your dentist can appeal to the California Department of Insurance and One of the supporting documents.

HEALTHCARE PROVIDER REQUEST FOR ASSISTANCE (HPRFA) http://www.insurance.ca.gov/01-consumers/101-help/upload/RFAhealth.pdf

Needed are copies of your Dental Insurance card.

That is why you must always have proof of dental insurance in your possession.

For Driver's License/Government Issued Photo ID and selfie (optional) to ensure the check-in process is as quick as possible

FOLLOW STEPS BELOW

1. With your smartphone, take a picture of the front and back of your Photo ID and Insurance Card prior to starting this form.

2. To upload your images, click the “Choose a file” button and locate "Photo library" on the image on your phone.

3. Do not use the “Take Photo or Video” feature within the form.

4. To ensure your images upload properly, take the photos BEFORE you start the form. Do not use the “Take Photo” feature within the form. Except in SELFIE UPLOAD BUTTON

Contact our office at 510-792-4525 (Newark)

if you have any questions. Or ask the Receptionist to help fill up these forms while waiting for your appointment

NOTE: Your files are fully encrypted with HIPAA-compliant software to ensure security and privacy.

Date / Time *

Date

Time

Patient Name *

Have you recently moved to a new Address? If Yes ( Please update your new address below) City, State, Zip Code *

Has there been any change in the patient’s health since the last dental visit? *

PLEASE SELECT FROM THE DROP DOWN MENU

Enter below if there is change since the last dental visit *

Do you have a New Phone Number? If Yes (Please update your new Telephone number below) *

Is the patient taking any new medications? if so, give the list of medication *

Do you take Bisphosphonate pills (a drug used for Osteoporosis or similar disease) *

PLEASE SELECT FROM THE DROP DOWN MENU

Do you have a latex allergy? *

PLEASE SELECT FROM THE DROP DOWN MENU

Any Allergies? *

PLEASE SELECT FROM THE DROP DOWN MENU

Please provide name and phone number of your Physician *

Your Emergency Contact’s name and phone number: *

Name *

First

Last

Signature *

ROTATE YOUR PHONE TO ENTER FULLSCREEN

Government ID FRONT. YOU CAN SKIP THIS BUT YOU MUST BRING YOUR ID TO THE RECEPTIONIST!