St. Francis Dental Center | Serving Our Patients Since 1962

WELCOME TO ST. FRANCIS DENTAL CENTER

PATIENT FORMS

St. Francis Dental Center offers the highest quality general dentistry services in the Milwaukee, WI region. For 50 years, we have provided superior service to our patients in the Bay View, St. Francis, Cudahy, and South Milwaukee areas of Wisconsin. To make your first appointment with us as convenient as possible, fill out the attached PDF forms and fax or bring them with you to your first appointment. Our fax number is: 414-744-6031

ST. FRANCIS DENTAL CENTER

NEW PATIENT FORM

PATIENT INFORMATION

Patient Name:



Partnered for years:

DENTAL INSURANCE


ASSIGNMENT AND RELEASE

I certify that I, and/or my dependent(s), have insurance coverage with and assign directly to Dr. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above-named dentist may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payments for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Phone Numbers

IN CASE OF EMERGENCY CONTACT (Specify someone who doesn't live in your household.)

Dental History






Bad Breath:
Bleeding Gums:
Blisters on lips or mouth:
Burning sensation on tongue:
Chew on one side of mouth:
Cigarette, pipe or cigar smoking:
Clicking or popping jaw:
Dry mouth:
Fingernail biting:
Food collection between the teeth:
Foreign objects:
Griding teeth:
Gums swollen or tender:
Jaw pain or tiredness:
Lip or cheek biting:
Loose teeth or broken fillings:
Mouth breathing:
Mouth pain, brushing:
Orthodontic treatment:
Pain around ear:
Periodontal treatment:
Sensitivity to cold:
Sensitivity to heat:
Sensitivity to sweets:
Sensitivity when biting:
Sores or growths in your mouth:



Health History

Physician's Name:
Date of last visit:

AIDS/HIV:
Anaemia:
Arthritis, Rheumatism:
Artificial Heart Valves:
Artificial Joints:
Asthma:
Back Problems:
Bleeding abnormally, with extractions or surgery:
Blood Disease:
Cancer:
Chemical Dependency:
Chemotherapy:
Circulatory Problems:
Congenital Heart Lesions:
Cortisone Treatments:
Cough, persistent or bloody:
Diabetes:
Emphysema:
Epilepsy:
Fainting or dizziness:
Glaucoma:
Headaches:
Heart Murmur:
Heart Problems:
Hepatitis Type:
Herpes:
High Blood Pressure:
Jaundice:
Jaw Pain:
Kidney Disease:
Liver Disease:
Low Blood Pressure:
Mitral Valve Prolapse:
Nervous Problems:
Pacemaker:
Psychiatric Care:
Radiation Treatment:
Respiratory Disease:
Rheumatic Fever:
Scarlet Fever:
Shortness of Breath:
Sinus Trouble:
Skin Rash:
Special Diet:
Stroke:
Swollen Feet or Ankles:
Swollen Neck Glands:
Thyroid Problems:
Tonsillitis:
Tuberculosis:
Tumour or growth on head or neck:
Ulcer:
Venereal Disease:
Weight Loss, unexplained:


WOMEN:




MEDICATIONS

List any medications you are currently taking and the corellating diagnosis:



ALLERGIES

Patient Signature:
Date:
Doctor's Signature:
Date:

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ST. FRANCIS DENTAL CENTER

FINANCIAL OPTIONS FORM

FINANCIAL OPTIONS

Welcome to St. Francis Dental Center! We are committed to provide you with the best possible care, and are pleased to discuss any of our professional fees with you at any time.

Full payment is due at the time of service for your dental treatment. For your convenience, we accept Visa, MasterCard, Discover and Care Credit.
We offer the following options for our self-pay patients:

  1. 7% courtesy for those who pay in full with cash/check, c/c the day of a scheduled appointment.
    (Only one courtesy may apply for any given patient or procedure.)
  2. Interest free financing though CareCredit.
  3. Automatic credit card withdrawal.

INSURANCE

Please remember you are fully responsible for all fees charged by this office regardless of your insurance coverage.

  • If you are insured, we will submit insurance for you. It is your responsibility as the insurance carrier, to provide the dental clinic with correct and complete insurance information. Your portion due for your dental investment will be due at time of service.
  • Any adult that accompanies a minor child and is the parent (or legal guardian) is responsible for full payment for that minor child at the time of service.

If collection action becomes necessary, I understand that I will be liable for collection agency fees (35% of balance) and/or attorney fees (45% of balance). In consideration of services provided to me, my minor children, I/we agree to pay charges not covered by insurance. Thank you for understanding our financial options. Please let us know if you have any questions or concerns. A copy of our financial options is available upon your request.

RESPONSIBLE PARTY

Signature:
Date:
 (Parent or Guardian must sign if patient is a minor)
Date:

I, authorize St. Francis Dental Center, Inc. to apply any co-payment to my credit card Visa/Master/Discover/CareCredit on behalf of myself and family. REQUIRED IF TREATMENT IS RENDERED WITHOUT PARENT PRESENT.

 
Exp:
Doctor's Signature:
Date:

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ST. FRANCIS DENTAL CENTER

NOTICE OF PRIVACY PRACTICES FORM


THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.

CONTACT INFORMATION

For more information about our privacy practices, to discuss questions or concerns, or to get additional copies of this notice, please contact our Privacy Officer






OUR LEGAL DUTY

We are required by law to protect the privacy of your protected health information (“medical information”). We are also required to send you this notice about our privacy practices, our legal duties, and your rights concerning your medical information.

We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect on the date set forth at the top of this page and will remain in effect unless we replace it.

We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make any change in our privacy practices and the new terms of our notice applicable to all medical information we maintain, including medical information we created or received before we made the change.

We may amend the terms of this notice at any time. If we make a material change to our policy practices, we will provide to you the revised notice. Any revised notice will be effective for all health information that we maintain. The effective date of a revised notice will be noted. A copy of the current notice in effect will be available in our facility and on our website if applicable. You may request a copy of the current notice at any time.

We collect and maintain oral, written and electronic information to administer our business and to provide products, services and information of importance to our patients. We maintain physical, electronic and procedural security safeguards in the handling and maintenance of our patients’ medical information, in accordance with applicable state and federal standards, to protect against risks such as loss, destruction or misuse.

USES AND DISCLOSURES OF YOUR MEDICAL INFORMATION

Treatment: We may disclose your medical information, without your prior approval, to another dentist, a physician or other health care provider working in our facility or otherwise providing you treatment for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, your health information may be disclosed to an oral surgeon to determine whether surgical intervention is needed.

Payment: We provide dental services. Your medical information may be used to seek payment from your insurance plan. For example, your insurance plan may request and receive information on dates that you received services at our facility in order to allow your employer to verify and process your insurance claim.

Health Care Operations: We may use and disclose your medical information, without your prior approval, for health care operations. Health care operations include:

  • Healthcare quality assessment and improvement activities;
  • Reviewing and evaluating dental care provider performance, qualifications and competence, health care training programs, provider accreditation, certification, licensing and credentialing activities;
  • Conducting or arranging for medical reviews, audits, and legal services, including fraud and abuse detection and prevention; and
  • Business planning, development, management, and general administration, including customer service, complaint resolutions and billing, de-identifying medical information, and creating limited data sets for health care operations, public health activities, and research.

We may disclose your medical information to another dental or medical provider or to your health plan subject to federal privacy protection laws, as long as the provider or plan has or had a relationship with you and the medical information is for that provider’s or plan’s health care quality assessment and improvement activities, competence and qualification evaluation and review activities, or fraud and abuse detection and prevention.

Your Authorization: You (or your legal personal representative) may give us written authorization to use your medical information or to disclose it to anyone for any purpose. Once you give us the authorization to release your medical information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or “revoke” your written authorization at any time in writing, except if we have already acted based on your authorization. Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect. Unless you give us a written authorization, we will not use or disclose your medical information for any purpose other than those described in this notice. We will obtain your authorization prior to using your medical information for marketing, fundraising purposes or for commercial use. Once authorized, you may opt-out of any of these communications.

Family, Friends, and Others Involved in Your Care or Payment for Care: We may disclose your medical information to a family member, friend or any other person you involve in your care or payment for your health care. We will disclose only the medical information that is relevant to the person’s involvement.

We may use or disclose your name, location, and general condition to notify, or to assist an appropriate public or private agency to locate and notify, a person responsible for your care in appropriate situations, such as a medical emergency or during disaster relief efforts.

We will provide you with an opportunity to object to these disclosures unless you are not present or are incapacitated or it is an emergency or disaster relief situation. In those situations, we will use our professional judgment to determine whether disclosing your medical information is in your best interest under the circumstances.

Health-Related Products and Services: We may use your medical information to communicate with you about health-related products, benefits, services, payment for those products and services, and treatment alternatives. Reminders: We may use or disclose medical information to send you reminders about your dental care, such as appointment reminders. Plan Sponsors: If your dental insurance coverage is through an employer’s sponsored group dental plan, we may share summary health information with the plan sponsor.

Reminders: We may use or disclose medical information to send you reminders about your dental care, such as appointment reminders.

Plan Sponsors: If your dental insurance coverage is through an employer’s sponsored group dental plan, we may share summary health information with the plan sponsor.

Public Health and Benefit Activities: We may use and disclose your medical information, without your permission, when required by law, and when authorized by law for the following kinds of public health and public benefit activities:

  • for public health, including to report disease and vital statistics, child abuse, and adult abuse, neglect or domestic violence;
  • to avert a serious and imminent threat to health or safety;
  • for health care oversight, such as activities of state insurance commissioners, licensing and peer review authorities, and fraud prevention agencies;
  • for research;
  • in response to court and administrative orders and other lawful processes;
  • to law enforcement officials with regard to crime victims and criminal activities;
  • to coroners, medical examiners, funeral directors, and organ procurement organizations;
  • to the military, to federal officials for lawful intelligence, counterintelligence, and national security activities, and to correctional institutions and law enforcement regarding persons in lawful custody; and

  • as authorized by state worker’s compensation laws.
  • If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law.

Business Associates: We may disclose your medical information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. Our business associates are required, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

Data Breach Notification Purposes: We may use your contact information to provide legally-required notices of unauthorized acquisition, access, or disclosure of your health information.

Additional Restrictions on Use and Disclosure: Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly confidential information” may include confidential information under Federal laws governing alcohol and drug abuse information and genetic information as well as state laws that often protect the following types of information:

  1. HIV/AIDS;
  2. Mental health;
  3. Genetic tests;
  4. Alcohol and drug abuse;
  5. Sexually transmitted diseases and reproductive health information; and
  6. Child or adult abuse or neglect, including sexual assault.

YOUR RIGHTS

Access: You have the right to examine and to receive a copy of your medical information, with limited exceptions. We will use the format you request unless we cannot practicably do so. You should submit your request in writing to our Privacy Officer.

We may charge you reasonable, cost-based fees for a copy of your medical information, for mailing the copy to you, and for preparing any summary or explanation of your medical information you request. Contact our Privacy Officer for information about our fees.

Disclosure Accounting: You have the right to a list of instances in which we disclose your medical information for purposes other than treatment, payment, health care operations, as authorized by you, and for certain other activities.

You should submit your request to our Privacy Officer. We will provide you with information about each accountable disclosure that we made during the period for which you request the accounting, except we are not obligated to account for a disclosure that occurred more than 6 years before the date of your request.

Amendment: You have the right to request that we amend your medical information. You should submit your request in writing to our Privacy Officer.

We may deny your request only for certain reasons. If we deny your request, we will provide you a written explanation. If we deny your request, you may have a statement of your disagreement added to your medical information. If we accept your request, we will make your amendment part of your medical information and use reasonable efforts to inform others of the amendment who we know may have and rely on the unamended information to your detriment, as well as persons you want to receive the amendment.

Restriction: You have the right to request that we restrict our use or disclosure of your medical information for treatment, payment or health care operations, or with family, friends or others you identify. Except in limited circumstances, we are not required to agree to your request. But if we do agree, we will abide by our agreement, except in a medical emergency or as required or authorized by law. You should submit your request to our Privacy Officer. Except as otherwise required by law, we must agree to a restriction request if:

  1. except as otherwise required by law, the disclosure is to a health plan for purposes of carrying out payment or health care operations (and not for purposes of carrying out treatment), and
  2. the medical information pertains solely to a health care item or service for which the health care provider involved has been paid out of pocket in full by the patient.

Confidential Communication: You have the right to request that we communicate with you about your medical information in confidence by means or to locations that you specify. You should submit your request in writing to our Privacy Officer.

Breach Notification: You have the right to receive notice of a breach of your unsecured medical information. Breach may be delayed or not provided if so required by a law enforcement official. You may request that notice be provided by electronic mail. If you are deceased and there is a breach of your medical information, the notice will be provided to your next of kin or personal representatives if we know the identity and address of such individual(s).

Electronic Notice: If you receive this notice on our web site or by electronic mail (e-mail), you are entitled to receive this notice in written form. Please contact our Privacy Officer to obtain this notice in written form.

COMPLAINTS

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your medical information, about amending your medical information, about restricting our use or disclosure of your medical information, or about how we communicate with you about your medical information (including a breach notice communication), you may contact to our Privacy Officer.

You also may submit a written complaint to the Office for Civil Rights of the United States Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, Washington, D.C. 20201. You may contact the Office for Civil Rights’ Hotline at 1-800-368-1019.

We support your right to the privacy of your medical information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

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ST. FRANCIS DENTAL CENTER

PRIVACY PRACTICES ACKNOWLEDGEMENT FORM


SECTION A: The Patient







SECTION B: Acknowledgement of Receipt of Privacy Practices Notice.

I, , acknowledge that I have received a Notice of Privacy Practices from the above-named practice.

If a personal representative signs this authorization on behalf of the individual, complete the following:

SECTION C: Good Faith Effort to Obtain Acknowledgement to Receipt.

SIGNATURE

I attest that the above information is correct.

Doctor's Signature:
Date:
Print Name: (Include this acknowledgement of receipt in the individual's form.)
Title:

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ST. FRANCIS DENTAL CENTER

FINANCIAL & INSURANCE INFORMATION

Keeping the cost of dentistry affordable for you and your family is a priority to us. We make every effort to ensure this for you.

  • Cost of treatment will be openly discussed with you, along with treatment options you may have.
  • Treatment plans are routinely filed to your insurance to assist you with their estimated payment.
  • Patient portions due day of service are given a 7% discount for all forms of payment, with the exception of CareCredit. Our office accepts: Visa, Master Card, Discover, personal checks and cash.
  • Monthly billing is available through our office with CareCredit, a national financing group that provides no interest plans for patient care. For more information, and to Apply Online, go to this link.

You can feel confident that every effort will be made by our knowledgeable business staff to assist you in understanding your insurance and in helping to make dentistry affordable for you.

ST. FRANCIS DENTAL CENTER

NEW PATIENT SPECIAL

OUR NEW PATIENT SPECIALS
St. Francis Dental Center | Serving Our Patients Since 1962

“Thank you very much for helping me keep my teeth healthy. I really appreciate your helping me. I promise that I will work hard in high school to help pay back all of the people who have helped me and my family. I hope you have a good rest of the summer.”

Jesus M.

“Ed and I want to extend our greatest appreciation for giving him a wonderful smile and a healthy bite. It was a real struggle to try and eat without teeth and you have made life a whole lot more enjoyable for him in more ways than one. You and your staff are some of the most giving and caring people we have ever met. The world is truly a better place with you in it.”

Ed & Marian S.

“I have recommended family and friends to Dr. Joseph Stiglitz, of St. Francis Dental Center, for over 25 years. We are 100% satisfied with the dental services performed, and we are totally pleased with the professional and friendly staff.”

Arlene B.

“My grandchildren are now patients at St. Francis Dental and actually enjoy going to see “Dr. Joe”. The hygienists have been wonderful with them and since the age of two, they have had a very positive experience. Everyone at the office is professional and pleasant. Along with my grandchildren, I enjoy my dental check-ups twice yearly and look forward to saying hello to all the great staff.”

Dorothy B.

“I can honestly say that I no longer have a fear of going to the dentist! Along with being, a first class-dentist, Dr. Stiglitz is an extremely pleasant person to deal with. He does not dismiss concerns, but always checks into them.”