New Patient Checklist (EagleSoft)
Patient name: ______Ph #______Date: ______Appt Date:______
Are you hurting or looking for a checkup? ______
May I ask you a few questions to smooth out your first visit?
You get to choose how you would like to start your first visit. If you are generally healthy, then having a cleaning/exam/xrays is a great start. Or, if you feel that you have a lot of treatment needs, then starting with a comprehensive exam/xrays will give you time to talk with Dr. ______and have her put together a plan for you. Which way sounds best to you?
3 options to schedule: (No NPs after 3pm on Fridays)
Emergency $116 / Child Dental cleaning/exam (NPC) $260 / Adult Comp exam (NPA) $284 / Adult cleaning only $26309110 – Palliative $100
0220 – Periapical Xray $16 / 1120 – Child prophy $43
0120 – Comp Exam $55
0272 – 2 Decay Xrays $32
1206 – Fluoride Varnish $40
0330 – Pano $90 / 0150 – Comp exam $55
0330 – Pano $90
00274 - 4 Decay Xrays $61
0110 – Cleaning $78 / 0110 – Cleaning $78
0120 – Exam $34
00274 - 4 Decay Xrays $61
0330 – Pano $90
1 hr asst / 1 hr RDH / 3u w/asst, 1 hr RDH / 1 hr RDH
To set you up properly for billing, who will be responsible for your account? – Enter this person’s information first as the guarantor. Then, add family members (Uncheck Responsible Party & then click on blue link and choose the guarantor).
Do you have dental insurance?
Policy holder – Name, Address, Phone, Birth Date, SSN; Has Primary Insurance, Employer that matches insurance carrier (check that the insurance address is correct)
In Edit Patient / Preferences – enter Insurance ID in the Primary Member ID field
Patient – Name, Choose Policy Holder as Responsible Party, Address, Phone, Birth Date, SSN; Choose Policy Holder for insurance
We are members of: Aetna, Ameritas, BCBS, Cigna, Delta Dental, Dentemax, CoverKids (DentaQuest), Guardian, HealthSpring, Humana, Lincoln Financial Group, MetLife, Principal Life, United Healthcare, United Concordia
Who should we thank for referring you to us?
When is the last time you had x-rays taken? Find out from patient – or call & ask insurance:
When was the last prophy? ______last BWX? ______last pano? ______
Is there anything in particular we can do to make you comfortable for your visit? (find out if they are anxious or afraid) ______
Would you like to go onto our website to print your health history forms or would you prefer to come in 15 minutes early to fill out paperwork here?
Checklist for NPs
o TennCare (last name CAPS) – No New Patients
o Use Employer TennCare & Insurance DentaQuest
o CoverKids (1st name CAPS) – schedule 11am–3pm only – set $1500 deductible & copay alert
o Use Employer CoverKids & Insurance DentaQuest
o Military patients (United Concordia) – when they schedule, get a control # (they get this from the military for each appt) and when they leave, we need to enter the control # & a dental readiness number (1-all well, 2- ok, 3-not good) in the claim notes
o Enter referral source (Edit patient – Referrals button)
o Insurance – Policy holder set up? Patient set up?
o Check eligibility (Edit patient - Eligibility button) – Print & Save – this shows benefits remaining
o If eligibility button no response: Lists / Letters / Insurance Verification Merge & Print – then call insurance to fill out this form
o Update Memo (Schedule – Memo) – use Lists/Ltrs/Ins memo template
o Enter remaining benefits & remaining deductible for this patient
o Set insurance info – Edit patient, blue employer link, enter remaining benefits & remaining deductible, fee schedule, coverage book & adjustment type, then enter %’s
o Make note in appt – take photo
o Special insurance setup:
o Must get member ID: BCBS, DentaQuest, HealthSpring, Humana
o All others – must get SSN
o If Assurant – use United Concordia fee schedule
T:\Forms and Handouts\New Patient Checklist.docx