The Phoenix HYG Exam Click on Hygienist Name Below * CindyMadisonRachelle PATIENT INFORMATION Preferred Name Full Name DI# HIPAA HAS HIPAA BEEN SIGNED *Has HIPAA Been Signed? YES- HIPAA SUBMITTED NO HIPAA SUBMITTED Please have Patient Sign HIPAA Click the Link Below to Fill out the HIPAA and Waiver Link Please copy the Patience name and the DI# into the HIPAA/Waiver link HIPAA & Waiver HIPAA HAS BEEN SIGNED HIPAA HAS BEEN SIGNED IF NOT ALREADY PREFILLED, INDICATE PATIENTS INSURANCE COMPANY BELOW: INSURANCE COMPANY United Healthcare United Healthcare Dual Humana Humana Dual Select Health Select Health Dual Aetna Aetna Dual Cigna Molina Dual Medicaid CLICK HERE ADDT'L SERVICES COVERED BY PATIENT'S INSURANCE ALL PLANS INLCUDE PREVENTATIVE CARE, INCLUDING SCREENING, ASSESSMENT, PROPHY & FLUORIDE SEALANTS COVERED ADULTS & CHILDREN PERIO MAINTENANCE PRE-AUTH NEEDED SCALING W/ INFLAMMATION NOT COVERED DEBRIDEMENT COVERED (DENTIST DIAGNOSIS NEEDED) DENTURES PRE-AUTH NEEDED SEALANTS COVERED ADULTS & CHILDREN PERIO MAINTENANCE COVERED SCALING W/ INFLAMMATION COVERED DEBRIDEMENT COVERED DENTURES COVERED SEALANTS COVERED FOR CHILDREN ONLY PERIO MAINTENANCE COVERED SCALING W/ INFLAMMATION COVERED DEBRIDEMENT COVERED DENTURES COVERED ONCE PATIENT INFO IS REVIEWED, CLICK ON "SERVICES COMPLETED" BELOW WHAT SERVICES ARE YOU PERFORMING TODAY? PATIENT INFOSERVICES COMPLETEDRECOMMENDED SERVICES Next Δ