On behalf of the entire team at Stunning Smiles of Las Vegas - Excellence in Dentistry, let me welcome you to our practice. We are grateful that you have chosen us to meet your dental needs, and trust that you will find your experience in our office to be pleasant, professional, and extraordinary.

You may discover that we are different from the average dental practice. When you visit our office you will find a unique and relaxing environment. Our team is friendly and attentive. All of our treatment is designed to be comfortable, to be long lasting, and to exceed all your expectations. We use the latest technology and techniques our profession has to offer. Our greatest strength lies in the unequaled advanced training in cosmetic and reconstructive dentistry we have received. It is for these simple reasons that we provide Excellence in Dentistry.

In order to better serve you, we are enclosing in this Welcome Packet several important documents that will assist us in making your transition to our office as smooth as possible. Please read each one carefully so that you can become familiar with our practice philosophy and policies. We are happy to answer questions you may have at any time.

Please find the enclosed questionnaire that should be filled out prior to your first appointment with Dr. Racanelli.

Be sure to visit our website at www.LVStunningSmiles.com. We look forward to serving all your dental needs for you and your family.

Yours truly for better dental health,
Richard A. Racanelli, DMD

REGISTRATION AND HEALTH HISTORY

*Your signature indicates you have received a copy of the HIPAA law and Dental Materials forms as well as releasing Richard A Racanelli, DMD to utilize any dental photographs for lecturing and educational purposes

COSMETIC/ESTHETIC EVALUATION

At Stunning Smiles of Las Vegas, though our focus is on appearance-related dentistry, our team also delivers routine general dental care as well. With flexible payment plans as well as phasing treatment over time, you and your family can achieve spectacular long-term results.
Thank you so much for the opportunity to be of service.

Warm Regards,
Richard A. Racanelli, DMD

It is necessary to develop a rapport with our patients. Many new patients have had a past unpleasant dental experience. It is crucial to us to know and understand your concerns. We are committed to taking the time to get to know you, discuss your concerns, your fears, and your dental expectations.

Partnership Pact:

I ask that you honestly inform me of all my dental problems. I want you to make me aware of the best quality dentistry available today. Then we can discuss how I can make healthy choices that will work within my budget. I also want to know all the pain relief options available to me, how each dental procedure will work, and how much of my time will be required.

SECTION A: PATIENT GIVING CONSENT

SECTION B: TO THE PATIENT - PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment. payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting our office at (702) 736-0016 or by mailing us at 6410 Medical Center St., Ste. B, Las Vegas, NV 89148.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the address above. Please understand that revocation of this Consent will not affect any action we took before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that by signing this Consent form I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.

If this Consent is signed by a personal representative on behalf of the patient, complete the following:

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.

You are entitled to receive our Notice of Privacy Practices upon request. This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

Included in the notice are:

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Your Choices

For certain health information, you can tell us your choices about what we share.

Other Uses and Disclosures

This section describes how we typically use or share your health information.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information. This section describes all of our responsibilities in protecting your information.

To Request a Copy

We will provide a copy of our Notice of Privacy Practices to you upon request. Use the options below to indicate your preference:

I have been offered a copy of the Stunning Smiles of Las Vegas Notice of Privacy Practices.

At Stunning Smiles of Las Vegas, we understand that your time is valuable. We are constantly striving to make your experience here more pleasant than any other place you have previously been. We make every effort to stay on time so that our patients will not have to wait unnecessarily.

Your appointment is a commitment of time between you and our office. We ask that you make every effort to keep that commitment. We do provide courtesy reminders and confirmation text messages at 30, 14, 7 & 3 days. Once you have confirmed your appointment with us, you will no longer receive the courtesy texts, EXCEPT for the same-day 2 hour reminder text about your upcoming appointment time.

If you need to change your scheduled appointment time with our office, we kindly ask for 48 hrs notice so that we can offer your reserved time slot to a patient on our waiting list.

Patients who have a history of changing their appointment within 48hrs of their reserved time or have no-called, no-showed to their appointments, whether confirmed or not, may not be able to pre-schedule and would go on a same day list for future appointments.

Thank you for choosing us as your dental care provider! We are committed to providing you with the best dental care available. Below we have outlined several payment options to help you get the dental treatment you may need, want and deserve.

Available Payment Options

You can choose from - Cash, check, all major credit cards

Financing is available, ask us for details.

Dental Insurance

For patients with dental insurance, we are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement on your behalf.

Your insurance is a contract between you and your insurance company. Stunning Smiles of Las Vegas is not part of that contract.

Not all services are covered benefits in all contracts. Some insurance companies arbitrarily select services they will and will not cover.

If your insurance carrier does not pay the estimated benefit in full, you will be immediately responsible for any remaining balance. This balance may include any deductibles, co payments, denials and non covered services.

Dental Benefits/Insurance

We will attempt to verify your benefit plan and give you as close of an estimate as we can for your treatment. Please understand that we don't know exactly how much your dental benefits will pay until the claim comes back. We do our best to give you an accurate estimate.

We will try to answer any questions we can about your dental benefit plan and, when possible we will assist in resolving any issues with claims. Your insurance contract is an agreement between you, your employer and your insurance carrier. In the event that your dental benefit company has not paid for your treatment, you will be responsible to pay your account.

Scheduling

We do collect your estimated patient portion or in order to reserve time in our doctor's schedule, or for an appointment time with our hygienist longer than 1 hour (except for new patient appts.). This allows us to provide the highest level of care to our patients. Should you have a residual balance after your insurance claim is closed, you will receive a statement in the mail. We accept payments over the phone with a credit card and in person, a mailed check or payment via a text link.

Collections on Balances due

A charge will be added to your account for any returned checks.

If you are experiencing financial difficulties in paying your balance, please reach out to use and we are happy to work with you to bring your account current.

After three statements or 45 days, your account may be turned over to a debt collector to bring the account current. You still would pay your outstanding bill to Stunning Smiles of Las Vegas. If your account is not settled or you have not set up a payment plan with us after 90 days, your account may go to a collection agency and you are responsible to pay the balance due, + 50% of the balance. This includes, but is not limited to fees to collect your balance.

Responsible Party

As the responsible party, in the case where my spouse and/or children are also patients at Stunning Smiles of Las Vegas, signing this Office & Financial Policies will apply to them and their accounts as well.

I authorize the professional office of my dentist, named above, to release health information identifying me (including if applicable, information about HIV infection or AIDS, information about substance abuse treatment, and information about mental health services) under the following conditions:

1. Detailed description of the information to be released:
2. To whom may the information be released (names or classes of recipients):
3. The purpose(s) for the release (if the authorization is initiated by the individual, it is permissible to state "at the request of the individual" as the purpose, if desired by the individual):
4. Expiration date or event relating to the individual or purpose for the release:

Other persons that my information may be shared with:

It is completely your decision whether or not to sign this authorization form. We cannot refuse to treat you if you choose to not sign this authorization.

If you sign this authorization, you can revoke it later. The only exception to your right to revoke is if we have already acted in reliance upon the authorization. If you want to revoke your authorization, send us a written or electronic note telling us your authorization is revoked. Send this note to the office contact listed above.

When your health information is disclosed as provided in this authorization, the recipient often has no legal duty to protect its confidentiality. In many cases, the recipient may re-disclose the information as he/she wishes. Sometimes, state or federal law changes this possibility.

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. I AUTHORIZE THE DISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBED IN THIS FORM.