ORALCARE
ASSOCIATES
Oral & Maxillofacial Surgery
Dale H. Minkin, D.D.S.
Diplomate, American Board of Oral and Maxillofacial Surgery
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39350 Civic Center Drive
Suite 320
Fremont, CA 94538
Tel (510) 797-9100
Fax (510) 797-3429
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WELCOME TO OUR PRACTICE
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FOR PATIENTS WITH INSURANCE
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Medical & Hospitalization Insurance
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PLEASE ANSWER ALL QUESTIONS
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PLEASE INQUIRE ABOUT ANY QUESTIONS WHICH ARE NOT UNDERSTOOD
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By my signature below, I agree and indicate that the above information is correct and current to the best of my knowledge, that I give consent to secure records such as X-rays, models, photographs, etc and perform whatever diagnostic procedures deemed necessary, and that all consent forms signed are an integral part of this treatment record and that neither is complete without the other.
If I am unable to keep an appointment, I will give 48 hour notice, otherwise a charge will be made for the time reserved.
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Date
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________________________
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Patient _________________________________________
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Patient or Legal Guardian ___________________________
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If you would like us to share medical or financial information with anyone other
than you, please complete the following: |
AUTHORIZATION FOR RELEASE OF MEDICAL/DENTAL RECORDS
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I hereby request and authorize the release of all information, without limitations, regarding any
physical and mental condition, as revealed by your observation or treatment, past, present or future.
This includes photocopies of medical and/or dental histories, x-ray findings, diagnosis, treatment,
prognosis and financial records.
I request that you release the above information to:
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Fill in the recipient
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Address
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City
State
Zip
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Patient's(or Legal Guardian's) Signature
Date
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Witness's Signature
Date
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Acknowledgement of Receipt of Notice of Privacy Policies. I have received a copy of OralCare Associates Notice of Privacy Policies.
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Patient Consent Form
Summary of Privacy Practices Form
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