Belleair Oral Surgery & Implants Ralph M. Eichstaedt, DDS

Transcription

1 Belleair Oral Surgery & Implants Ralph M. Eichstaedt, DDS Patient s Information First Name: Last Name: of Birth: Social Security #: Sex: Male Female Marital Status: Single Married Divorced Widowed Separated Mailing Address: City, State, Zip: DL # (of responsible party): Home Phone: Work Phone: Mobile Phone: Employer: Address: Emergency Contact: Phone #: Relation: How were you referred to our office? Dentist Medical Doctor Insurance Company Other Name: Responsible Party (Only if patient is under 18) First Name: Last Name: of Birth: Social Security #: Relationship to patient: Marital Status: Single Married Divorced Widowed Separated Sex: Male Female Mailing Address: City, State, Zip: Home Phone: Work Phone: Mobile Phone: Employer: Address: If Accident Related Due to injury? Yes No If yes, injury date: On the job Auto accident Other: Insurance Name: Phone: Company Address: City, State, Zip: Please complete back side of form

2 Financial Polices Our goal is to provide the highest quality of dental care possible and to have clear communication of our financial policy. Payment Policies: Full payment is collected at the time services are rendered, unless prior arrangements have been made with the Office Manager prior to the appointment. If a treatment plan requires multiple stages, payment will be required at the time services for that stage are rendered. We accept Cash, Checks, Visa, MasterCard, Discover, American Express, and Care Credit. A NSF fee will be charged to the patient in the event that their check is returned to us for non-payment. Dental Benefits: If you have provided us with your dental benefit information, we will file your claim as a complimentary service for you. If you are in-network, your co-pay and/or deductible are due on the day of service. We are happy to provide you with an estimate of what we believe your dental benefits will cover based on the information provided to us from your benefit provider. Please know that we cannot guarantee what will be covered by your dental benefits. Preauthorization by your insurance company is not a guarantee of the quoted benefit. We are happy to help you review your dental benefits and answer any questions you have, however, you are responsible for understanding your benefits. You have ultimate financial responsibility for your account regardless of whether your dental benefit provider covers your treatment. Insurance will not guarantee any benefit until we actually file the claim. I also understand that I am responsible for any copayments, deductibles or billable charges due to plan limitations/exclusions and/or that are not covered and/or denied by my insurance company. The patient is responsible for any additional monies owed after insurance pays. Patient is also responsible for all insurance claims not paid within 90 days of service. Medical Benefits: We are not contracted with any medical plans. We will take a copy of your medical insurance cards to put on file but we will not bill any medical companies. We are more than happy to give you anything you need for you the patient to bill your medical on your own for insurance to reimburse you directly. Patients with Medicare: Dental procedures are not billable expenses to Medicare. However, if you will be having a medical procedure only, please provide us with your Medicare information and we will submit your claim. This notice is to also inform our Medicare patients that their secondary insurance may or may not pay us because we are not contracted with any medical plans except Medicare. If the secondary pays they might send the check to us or they might send it to the patient. If you receive a check from the insurance you would need to forward us that amount. If the secondary does not pay then you would be responsible for the co-insurance that is due and this does include if your secondary is Medicaid. Medicaid will not pay as we are not contracted with them. Cancellation and Failed Appointments: We work hard to stay on schedule for you and expect the same level of consideration from our patients. Because instruments, chairs and personnel are reserved exclusively for your appointment we ask if you anticipate that you will not be able to honor your reserved appointment time, please contact our office with 24 hours. Patients who are repeatedly late or are absent for scheduled appointments may be dismissed from our practice. Appointments scheduled for over 1.5 hours: A 20% retainer fee will be collected to reserve your scheduled time for appointment times that are longer than 1.5 hours. The 20% retainer will be applied toward your co-pay and or deductible due for treatment. If less than 48 hours notice is given to cancel or you fail to arrive for these types of appointments, a cancellation fee will be charged. The cancellation fee is not applied toward your copay and/or deductible and will come out of the 20% retainer. Minors: If a patient is under the age of 18, a parent or legal guardian must accompany the patient to each appointment to review medical history, authorize treatment unless prior arrangements have been made with the office manager prior to the patient appointment. Patient s under 21 years old: If the patient is under 21 years old we must know who is responsible to the patient s account. If the patient s account ever ended up with a refund that we needed to send back to the patient please clearly list the name and address this refund would go to: By signing below you that you have read and understand and agree to the above polies. I also certify that the information I have reported with regard to my insurance coverage is correct and I authorize the release of any information relating to any claim for benefits, in order to process any claim for benefits. Furthermore, I permit a copy of this authorization to be used in place of the original. X Patient or Guardian Signature

3 Patient Medical History Patient s Name: DOB: Age: Height: Weight: The following medical information is for your general welfare, whether you are here for diagnostic consultation, a simple extraction, or a major oral surgical procedure. Your general health may have a significant affect on your current condition and on the outcome of any proposed treatment. For the sake of your overall health and safety, please answer all questions. Please circle Yes or No and explain where necessary. Yes / No Are you seeing a specialist now (cardiologist/hematologist, etc.)? Yes / No Are you under the active care of a physician for any reason? Yes / No When was your last physical examination. Was anything unusual or abnormal found? Yes / No Are there any other medical conditions we should be aware of? Yes / No Are you taking diet pills at this time? Yes / No Have you ever taken any of following diet pills? Fen-Phen (fenfluramine & phentermine) Pondimin (fenfluramine) Redux (dexfenfluramine) Yes / No If you have ever taken any of the above drugs, have you had a medical examination to insure that your heart valves were not affected? Yes / No Do you have a cough or cold at this time? Yes / No Do you use tobacco products? Type Usage Yes / No Do you drink alcoholic beverages? Usage Yes / No Personal or family history of problems with anesthesia including malignant hyperthermia (MH)? General Dentist Name: Phone Number: Medical Doctor s Name: Phone Number: Women Only Yes / No Pregnant/Trying to get pregnant? Yes / No Taking oral contraceptives? Yes / No Nursing? Do you have, or have you ever had any of the following? Please mark all that apply. ( ) Heart Murmur/Abnormal Heart Sound ( ) Kidney Disease ( ) Anxiety/Depression/ ( ) Irregular Heart Beat ( ) Painful Joints Psychiatric Illness Requiring ( ) Rheumatic Fever/Rheumatic Heart Disease ( ) Pain In Chest Treatment by a Psychiatrist/ ( ) Heart Disease/Heart Attack ( ) Pain In Arms Psychologist ( ) Lung Trouble/TB/+PPD ( ) Arthritis Have you ever had allergies to: ( ) Shortness of Breath ( ) Asthma/Bronchitis/Pneumonia ( ) Any Foods: ( ) Swelling of Ankles ( ) Snoring/Sleep Apnea ( ) Anemia/Sickle Cell Disease ( ) A.C.T.H./Steroids ( ) Penicillin ( ) High or Low Blood Pressure ( ) Blood Transfusion/ ( ) Aspirin ( ) Diabetes Told you cannot donate blood? ( ) Codeine ( ) Bleeding Problems/Bleed or Bruise Easily ( ) Ulcers ( ) Demerol ( ) Cerebrovascular Disease (Stroke/TIA) ( ) Thyroid Disease ( ) Iodine ( ) Prosthetic Joint Surgery (Artificial) ( ) Glaucoma ( ) Anesthetics (such as ( ) Dizziness/Fainting ( ) Immune System Compromise/ Novocain, etc.) ( ) Jaundice or Liver Disease/Hepatitis Frequent Infections ( ) Latex ( ) Sinus Problems ( ) Tumor/Cancer/Radiation Treatment/ ( ) Other Drugs: ( ) Convulsions/Seizures/Epilepsy Chemotherapy Please complete back side of form

4 Patient s Name: Please list current medications, including over the counter medication and supplements. Please list all surgeries: I understand the importance of providing a truthful health history to assist my doctor in providing the best care possible. I certify that the information provided here is accurate and complete and that I will ask questions of my doctor and assisting staff to clarify any items I do not understand. Signature of Patient or Responsible Party (only if under 18) Relationship to Patient DOCTOR S REVIEW Doctor signature MEDICAL HISTORY UPDATE (to be filled out at follow-up appointment) Yes / No Has there been any changes in y our health since you last reviewed this form? Yes / No Are you on or taking any new medications? Doctor signature Notes (office staff only):

5 BELLEAIR ORAL SURGERY & IMPLANTS PERMISSION TO DISCUSS YOUR HEALTH INFORMATION WITH OTHER INDIVIDUALS Patient Name: D.O.B: May we you with your personal health information (Example: X-rays, Financials, Office notes) Yes No If yes, please provide us with you address: May we /fax or discuss your person health information to/with other physicians participating in your care such as your general dentist, primary care physician, or a specialists (Example: X-Rays, Financials, Office notes, Test results or care received) Yes No Please list the names of individuals with whom are not one of your physicians that we may discuss your private health information with (Example: Treatment performed, Financials) Name Relationship to Patient Contact Number By signing this form, I hereby grant permission to the staff of Belleair Oral Surgery & Implants to discuss information related to my care with the individuals listed above (This release includes all physicians that are an active part of my care.) Signature: (Patients that are 18 years and older must sign this form. The signature of a parent, guardian or spouse is not acceptable.) Relationship to patient: : Please complete back side of form

6 BELLEAIR ORAL SURGERY & IMPLANTS NOTICE OF PRIVACY POLICIES CONSENT Our Notice of Privacy Policies provides information about how we may use and disclose Protected Health Information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how Protected Health Information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. By signing this form, you consent to our use and disclosure of Protected Health Information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The patient understands that: Protected Health Information may be disclosed or used for treatment, payment or health care operations. The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice. The Practice reserves the right to change the Notice of Privacy Policies. The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions. The patient may revoke this Consent in writing at any time and all future disclosures will then cease. The Practice may condition treatment upon the execution of this Consent. Patient (or Legal Guardian s) Signature Relationship to patient