NEW PATIENTS

NEW PATIENT INFORMATION


PATIENT INFORMATION

Welcome

Doctors Davis, Beyer, Lewicki, Brower and staff are dedicated to providing you with a pleasant visit and results that you’re proud to show off. Our administrative staff is ready to help you with questions about scheduling, financial policy and insurance, to make that part of the process as simple as possible.


This section offers information from the administrative side of the practice, including:

  • Patient Registration forms, HIPPA and Records release PDF's (All Fillable Forms)
  • New Patients
  • Scheduling
  • Financial Policy

INSTRUCTIONS

  1. Please download individual forms and save to your computer.
  2. Fill in each form completely and save the file.
  3. Upload individual files through the window listed to the right

  Upload individual forms

For additional assistance please call  

  941-488-1075     

  • Patient Registration

    Your initial appointment will consist of a Comprehensive Examination or a Periodontal Examination. Sometimes, treatment can be done or started the same day as the examination. However, a complex medical history or treatment plan may require additional appointments. Dental Cleanings are scheduled as a follow-up appointment after the initial examination is completed by one of our dentists. Your dentist has reserved this examination appointment time for you. Any appointment changes within 24 hours of your scheduled appointment time may incur a fee. 


    Please assist us by providing the following information in advance of your examination:


           A complete patient intake form and medical history.


      Please alert the office if you have a medical condition that may be of concern prior to treatment (i.e., diabetes, high blood pressure, artificial heart valves and joints, rheumatic fever, dental anxiety, etc.) or if you are currently taking any medication (i.e., heart medications, aspirin, anticoagulant therapy, etc.)


           A list of medications you are presently taking. Please note this is vital information to our treatment planning. 


           Any x-rays taken within the past 1-3 years by a previous dentist. 


      If your dentist or physician has taken x-rays, you may request that they forward them to our office. If there is not enough time, please pick them up and bring them to our office. If additional x-rays are necessary, they can be taken at our facility.


           If you have dental insurance, please provide the necessary verification form. This will save time and allow us to help you process any claims.


    IMPORTANT: All patients under the age of 18 must be accompanied by a parent or guardian.


    You may either email all completed forms to records@venicedentist.com,  or present to the office 15 minutes prior to your appointment time with this paperwork.


    For more information, please contact the our office @ (941)488-1075 .

  • Financial Policy

    For your convenience we accept Cash, Checks, and all major credit/Debit Cards.  Care Credit is also offered if additional financing options are  required. We deliver the finest care at the most reasonable cost to our patients, therefore payment is due at the time service is rendered unless other arrangements have been made in advance. Many times, a simple telephone call will clear any misunderstandings.


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


    If there is an outstanding balance after your account has been audited, we will send you a monthly statement. Most insurance companies will respond within four to six weeks.  Please call our office if your statement does not reflect your insurance payment within that time frame. Any remaining balance after your insurance has paid is your responsibility. Your prompt remittance is appreciated. 

  • Insurance

    Dental Insurance Information

    Please let us know if you have dental insurance or Medicare supplemental dental coverage, prior to your appointment.  Our Practice is an unrestricted Provider. This means our providers do not participate as “in-network” providers with any insurance plans.   However, if you provide your PPO insurance information, we will be pleased to courtesy file insurance claims and pre-determinations to your carrier on your behalf. We do not file insurance claims for HMO or DMO plans. 


    Insurance carriers are instructed to mail reimbursement checks directly to you.  If the insurance carrier inadvertently sends the check to the office, we will do what we can to get your reimbursement to you as soon as possible.


    Many patients think their insurance will reimburse the entire service fee for treatment.  Most plans only reimburse a percentage of the “usual and customary” fees the insurance company calculates. Pre-determinations can be obtained, but they do not guarantee reimbursement. Call the number on the back of your insurance card for more information on your plan’s reimbursement rates. 


    If you are 65 years old or older, Medicare is your primary medical insurance. Medical insurance does not typically cover dental procedures, such as extractions, implants, or other surgical procedures.  Our office does not provide courtesy filing for medical insurance claims. In the rare case where your dental procedure may be covered by medical insurance, the office will provide a statement of treatment rendered which will include codes needed for you to submit your claim to your medical insurance provider.  


    If you have additional questions, please contact our office @ (941) 488-1075. 


  • NOTICE OF PRIVACY PRACTICES

    THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED,


    HOW YOU CAN GET ACCESS TO THIS INFORMATION, YOUR RIGHTS CONCERNING YOUR HEALTH INFORMATION AND OUR RESPONSIBILITIES TO PROTECT YOUR HEALTH INFORMATION.


    PLEASE REVIEW IT CAREFULLY


    State and Federal laws require us to maintain the privacy of your health information and to inform you about our privacy practices by providing you with this Notice. We are required to abide by the terms of this Notice of Privacy Practices. This Notice will take effect on and will remain in effect until it is amended or replaced by us.


    We reserve the right to change our privacy practices provided law permits the changes. Before we make a significant change, this Notice will be amended to reflect the changes and we will make the new Notice available upon request. We reserve the right to make any changes in our privacy practices and the new terms of our Notice effective for all health information maintained, created and/or received by us before the date changes were made.


    You may request a copy of our Privacy Notice at any time by contacting our Privacy Officer, Information on contacting us can be found at the end of this Notice


    We will keep your health information confidential, using it only for the following purposes:


    Treatment: While we are providing you with health care services, we may share your protected health information (PHI) including electronic protected health information (ePHI) with other health care providers, business associates and their subcontractors or individuals who are involved in your treatment, billing, administrative support or data analysis. These business associates and subcontractors through signed contracts are required by Federal law to protect your health information. We have established "minimum necessary" or "need to know" standards that limit various staff members' access to your health information according to their primary job functions. Everyone on our staff is required to sign a confidentiality statement.


    Payment : We may use and disclose your health information to seek payment for services we provide to you. This disclosure involves our business office staff and may include insurance organizations, collections or other third parties that may be responsible for such costs, such as family members.


    Disclosure: We may disclose and/or share protected health information (PHI) including electronic disclosure with other health care professionals who provide treatment and/or service to you. These professionals will have a privacy and confidentiality policy like this one. Health information about you may also be disclosed to your family, friends and/or other persons you choose to involve in your care, only if you agree that we may do so. As of March 26, 2013, immunization records for students may be released without an authorization (as long as the PHI disclosed is limited to proof of immunization). If an individual is deceased, you may disclose PHI to a family member or individual involved in care or payment prior to death. Psychotherapy notes will not be used or disclosed without your written authorization. Genetic Information Nondiscrimination Act (GINA) prohibits health plans from using or disclosing genetic information for underwriting purposes. Uses and disclosures not described in this notice will be made only with your signed authorization


    Right to an Accounting of Disclosures : You have the right to request an accounting of disclosures" of your protected information if the disclosure was made for purposes other than providing services, payment, and or business operations. In light of the increasing use of Electronic Medical Record technology (EMR), the HITECH Act allows you the right to request a copy of your health information in electronic form if we store your information electronically. Disclosures can be made available for a period of 6 years prior to your request and for electronic health information 3 years prior to the date on which the accounting is requested. If for some reason we aren't capable of an electronic format, a readable hardcopy will be provided. To request this list or accounting of disclosures, you must submit your request in writing to our Privacy Officer. Lists, if requested, will be $  for each page and the staff time charged will be $ per hour including the time required to locate and copy your health information. Please contact our Privacy Officer for an explanation of our fee structure. May 23, 2016 OCR clarified a flat fee for electronic copies may not exceed $6.50 (including labor for copies, supplies and postage); this does not mean that the ceiling for all requests for access is $6.50.


    Right to Request Restriction of PHI : If you pay in full out of pocket for your treatment, you can instruct us not to share information about your treatment with your health plan; if the request is not required by law. Effective March 26, 2013, The Omnibus Rule restricts provider's refusal of an individual's request not to disclose PHI.


    Non-routine Disclosures : You have the right to receive a list of non-routine disclosures we have made of your health care information. You can request non-routine disclosures going back 6 years starting on April 14, 2003.


    Emergencies : We may use or disclose your health information to notify or assist in the notification of a family member or anyone responsible for your care, in case of any emergency involving your care, your location, your general condition or death. If at all possible, we will provide you with an opportunity to object to this use or disclosure. Under emergency conditions or if you are incapacitated, we will use our professional judgment to disclose only that information directly relevant to your care. We will also use our professional judgment to make reasonable inferences of your best interest by allowing someone to pick up filled prescriptions, x-rays or other similar forms of health information and/or supplies unless you have advised us otherwise.


    Healthcare Operations : We will use and disclose your health information to keep our practice operable. Examples of personnel who may have access to this information include, but are not limited to, our medical records staff, insurance operations, health care clearinghouses and individuals performing similar activities.


    Required by Law : We may use or disclose your health information when we are required to do so by law. (Court or administrative orders, subpoena, discovery request or other lawful process.) We will use and disclose your information when requested by national security, intelligence and other State and Federal officials and/or if you are an inmate or otherwise under the custody of law enforcement.


    National Security : The health information of Armed Forces personnel may be disclosed to military authorities under certain circumstances. If the information is required for lawful intelligence, counterintelligence or other national security activities, we may disclose it to authorized federal officials.


    Abuse or Neglect : We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. This information will be disclosed only to the extent necessary to prevent a serious threat to your health or safety or that of others.


    Public Health Responsibilities : We will disclose your health care information to report problems with products, reactions to medications, product recalls, disease/infection exposure and to prevent and control disease, injury and/or disability.


    Marketing Health-Related Services : We will not use your health information for marketing purposes unless we have your written authorization to do so. Effective March 26, 2013, we are required to obtain an authorization for marketing purposes if communication about a product or service is provided and we receive financial remuneration (getting paid in exchange for making the communication). No authorization is required if communication is made face-to-face or for promotional gifts.


    Fundraising : We may use certain information (name, address, telephone number or e-mail information, age, date of birth, gender, health insurance status, dates of service, department of service information, treating physician information or outcome information) to contact you for the purpose of raising money and you will have the right to opt out of receiving such communications with each solicitation. Effective March 26, 2013, PHI that requires a written patient authorization prior to fundraising communication include: diagnosis, nature of services and treatment. If you have elected to opt out we are prohibited from making fundraising communication under the HIPAA Privacy Rule.


    Sale of PHI : We are prohibited to disclose PHI without an authorization if it constitutes remuneration (getting paid in exchange for the PHI). "Sale of PHI" does not include disclosures for public health, certain research purposes, treatment and payment, and for any other purpose permitted by the Privacy Rule, where the only remuneration received is "a reasonable cost-based fee to cover the cost to prepare and transmit the PHI for such purpose or a fee otherwise expressly permitted by law. Corporate transactions (i.e., sale, transfer, merger, consolidation) are also excluded from the definition of "sale."


    Appointment Reminders : We may use your health records to remind you of recommended services, treatment or scheduled appointments.


    Access : Upon written request, you have the night to inspect and get copies of your health information (and that of an individual for whom you are a legal guardian.) We will provide access to health information in a form/ format requested by you. There will be some limited exceptions. If you wish to examine your health information, you will need to complete and submit an appropriate request form. Contact our Privacy Officer for a copy of the request form. You may also request access by sending us a letter to the address at the end of this Notice. Once approved, an appointment can be made to review your records. Copies, if requested, will be $f or each page and the staff time charged will be S per hour including the time required to copy your health information. If you want the copies mailed to you, postage will also be charged. Access to your health information in electronic form if (readily producible) may be obtained with your request. If for some reason we aren't capable of an electronic format, a readable hardcopy will be provided. If you prefer a summary or an explanation of your health information, we will provide it for a fee. Please contact our Privacy Officer for an explanation of our fee structure. May 23, 2016 OCR clarified a flat fee for electronic copies may not exceed $6.50 (including labor for copies, supplies and postage); this does not mean that the ceiling for all requests for access is $6.50.


    Amendment : You have the right to amend your healthcare information, if you feel it is inaccurate or incomplete. Your request must be in writing and must include an explanation of why the information should be amended. Under certain circumstances, your request may be denied.


    Breach Notification Requirements : It is presumed that any acquisition, access, use or disclosure of PHI not permitted under HIPAA regulations is a breach. We are required to complete a risk assessment, and if necessary, inform HHS and take any other steps required by law. You will be notified of the situation and any steps you should take to protect yourself against harm due to the breach


    QUESTIONS AND COMPLAINTS

    You have the right to file a complaint with us if you feel we have not complied with our Privacy Policies. Your complaint should be directed to our Privacy Officer. If you feel we may have violated your privacy rights, or if you disagree with a decision we made regarding your access to your health information, you can complain to us in writing. Request a Complaint Form from our Privacy Officer. We support your right to the privacy of your information and 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.


    If you have questions regarding the office policy, please contact us @ (941) 488-1075

For your convenience we accept Cash, Checks, and all major credit/Debit Cards. Lending Club Patient Solutions and Care Credit is also offered if additional financing options are required. We deliver the finest care at the most reasonable cost to our patients, therefore payment is due at the time service is rendered unless other arrangements have been made in advance. Many times, a simple telephone call will clear any misunderstandings.

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

If there is an outstanding balance after your account has been audited, we will send you a monthly statement. Most insurance companies will respond within four to six weeks. Please call our office if your statement does not reflect your insurance payment within that time frame. Any remaining balance after your insurance has paid is your responsibility. Your prompt remittance is appreciated. 

Home & Post Operative Instructions

  • After Cosmetic Reconstruction

    Remember that it will take time to adjust to the feel of your new bite. When the bite is altered or the position of the teeth is changed it takes several days for the brain to recognize the  new position of your teeth or their thickness as normal. If you continue to detect any high spots or problems with your bite, call our office.


    It is normal to experience some hot and cold sensitivity. The teeth require some time to heal after removal of tooth structure and will be sensitive in the interim. Your gums may also be sore for a few days. Warm salt water rinses (a teaspoon of salt in a cup of warm water) three times a day will reduce pain and swelling. A mild pain medication (one or two tablets of Tylenol or Ibuprofen (Motrin) every 4-6 hours) should ease any residual discomfort.


    Don’t be concerned if your speech is affected for the first few days. You’ll quickly adapt and be speaking normally. You may notice increased salivation. This is because your brain is responding to the new size and shape of your teeth. This should subside to normal in about a week.


    Daily brushing and flossing are a must for your new dental work. Daily plaque removal is critical for the long-term success of your new teeth, as are regular cleaning appointments.


    Any food that can crack, chip or damage a natural tooth can do the same to your new teeth. Avoid hard foods and substances (such as beer nuts, peanut brittle, ice, fingernails, or pencils) and sticky candies. Smoking will stain your new teeth. Minimize or avoid foods that stain such as coffee, red wine, tea and berries


  • After Crown and Bridge Appointments

    Dental crowns and dental bridges usually take two or three appointments to complete. In the first visit, the teeth are prepared and molds of the mouth are taken. Temporary dental  crowns or dental bridges are placed to protect the teeth while the custom restoration is being made. Since the teeth will be anesthetized, the tongue, lips and roof of the mouth may be numb. Please refrain from eating and drinking hot beverages until the numbness is completely worn off.


    Occasionally a temporary crown may come off. Call the office @ (941) 488-1075 if this happens and bring the temporary crown with you so we can re-cement it. It is very important  for the temporary to stay in place, as it will prevent other teeth from moving and compromising the fit of your final restoration.


    To keep your temporaries in place, avoid eating sticky foods (gum), hard foods, and if possible, chew on the opposite side of your mouth. It is important to brush normally, but floss carefully and don’t pull up on the floss which may dislodge the temporary but pull the floss out from the side of the temporary crown.


    It is normal to experience some temperature and pressure sensitivity after each appointment. The sensitivity should subside a few weeks after the placement of the final restoration. Mild pain medications may also be used as directed by our office.


  • After Tooth Extraction

    After tooth extraction, it’s important for a blood clot to form to stop the bleeding and begin the healing process. That’s why we ask you to bite on a gauze pad for 30-45 minutes  after the appointment. If the bleeding or oozing still persists, place another gauze pad and bite firmly for another 30 minutes. You may have to do this several times.


    After the blood clot forms, it is important not to disturb or dislodge the clot as it aids healing. Do not rinse vigorously, suck on straws, smoke, drink alcohol or brush teeth next to the extraction site for 24-48 hours. These activities will dislodge or dissolve the clot and retard the healing process. Limit vigorous exercise for the next 24 hours as this will increase blood pressure and may cause more bleeding from the extraction site.


    After the tooth is extracted you may feel some pain and experience some swelling. An ice pack or an unopened bag of frozen peas or corn applied to the area will keep swelling to a minimum. Take pain medications as prescribed. The swelling usually subsides after 48 hours.


    Use the pain medication as directed. Call the office if the medication doesn’t seem to be working. If antibiotics are prescribed, continue to take them for the indicated length of time, even if signs and symptoms of infection are gone. Drink lots of fluid and eat nutritious soft food on the day of the extraction. You can eat normally as soon as you are comfortable.


    It is important to resume your normal dental routine after 24 hours. This should include brushing and flossing your teeth at least once a day. This will speed healing and help keep your mouth fresh and clean.


    After a few days you will feel fine and can resume your normal activities. If you have heavy bleeding, severe pain, continued swelling for 2-3 days, or a reaction to the medication, call  our office immediately at (941) 488-1075 . 


Use the pain medication as directed. Call the office if the medication doesn’t seem to be working. If antibiotics are prescribed, continue to take them for the indicated length of time, even if signs and symptoms of infection are gone. Drink lots of fluid and eat nutritious soft food on the day of the extraction. You can eat normally as soon as you are comfortable.

It is important to resume your normal dental routine after 24 hours. This should include brushing and flossing your teeth at least once a day. This will speed healing and help keep your mouth fresh and clean.

After a few days you will feel fine and can resume your normal activities. If you have heavy bleeding, severe pain, continued swelling for 2-3 days, or a reaction to the medication, call our office immediately at (941) 488-1075.

  • After Composite Fillings (white fillings)

    When an anesthetic has been used, your lips and tongue may be numb for several hours after the appointment. Avoid any chewing and hot beverages until the numbness has  completely worn off. It is very easy to bite or burn your tongue or lip while you are numb.


    It is normal to experience some hot, cold & pressure sensitivity after your appointment. Injection sites may also be sore. Ibuprofen (Motrin), Tylenol or aspirin (one or two tablets every 4-6 hours as needed for pain) work well to alleviate the tenderness. If pressure sensitivity persists beyond a few days or if the sensitivity to hot or cold increases, contact our as soon as possible


    You may chew with your composite fillings as soon as the anesthetic completely wears off, since they are fully set when you leave the office.


    If your bite feels uneven, if you have persistent pain, or if you have any other questions or concerns, please call our office at (941) 488-1075 .

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