Palm Valley Oral and Maxillofacial Surgery

Transcription

1 Palm Valley Oral and Maxillofacial Surgery PATIENT INFORMATION: Male Female Single Married Divorced Widow Minor Name Soc.Sec # Address Apt# City State Zip Home Phone # Work Phone # Cell# Date of Birth Age Address If full time student, Name of School Employer Address Occupation Name of parent or guardian accompanying minor Soc.Sec# Relationship to minor Home# Work# Cell# Address Apt# City State Zip Employer Address Occupation Phone number Person to contact in case of Emergency Phone# Relationship Name of friend or relative NOT living with you Phone PRIMARY DENTAL INSURANCE Name of Policy Holder/Primary Insured Soc. Sec # DOB SECONDARY DENTAL INSURANCE PRIMARY MEDICAL INSURANCE SECONDARY MEDICAL INSURANCE Who may we thank for referring you to our office? Patient s General Dentist Phone # For children under 18 years of age, the parent accompanying the child to this appointment is deemed the responsible party for payment of this account. ASSIGNMENT AND RELEASE: I hereby assign my insurance benefits to be paid directly to Palm Valley Oral & Maxillofacial Surgery and authorize the release of any information required to process my claims. I understand that regardless if I have insurance or not, that I am financially responsible for all services rendered. I authorize the use of this signature on all insurance submissions. Signature of patient or responsible party (if minor) Date

2 PALM VALLEY ORAL & MAXILLOFACIAL SURGERY CONFIDENTIAL MEDICAL HISTORY FORM Name: Date: DOB / / Sex: M / F Ht. Wt Medications Do you have any allergies to any medications or foods? Please specify: Are you allergic to Latex? List ALL medications, non-prescriptions, homeopathics, or herbals you have been taking for the last 6 months (include diet supplements) Have you ever taken any of the following medications for any reason: (please circle) Zometa (zoledronic acid), Aredia (pamidronate), Actonel (risedronate), Fosamax (alendronate), Ostac or Bonefos (clodronate), Didronel (edtidronate), Boniva (ibandronate) Medical History Are you in good health? Have you had any previous serious illnesses or hospitalization? Has there been any significant change in your health this past year? My last physical exam was on / / Are you currently under the care of a physician? If so, for what condition? Name and address of your physician Phone: Have you ever received a general or local anesthetic? Have you had a reaction to general or local anesthesia? Specify: Reactions to general or local anesthesia? (include you and/or your family) Specify Answer Yes or No to the following health questions; please be specific when necessary so that we may give you the best care. Heart Health Do you currently see a Cardiologist (heart doctor) for any reason? Have you ever had a heart attack? Date: Do you have angina? (chest pain) Do you have Rheumatic Heart disease? Do you have a heart murmur? Do you take antibiotics before going to the dentist? Do you have high blood pressure? Do you have low blood pressure? Do you take medication for elevated cholesterol? Do you have damaged heart valves, artificial heart valves? Do you have an abnormal heart rhythm or arrhythmia? Do you have chest pain with exercise or physical exertion? Do you have a history of Congestive Heart Failure (fluid on the lungs?)? Hospitalization for this? Date: Do you experience shortness of breath after mild exertion?

3 Do your ankles swell? Have you had a cardiac catheterization? Date: Do you have heart stents or have you had angioplasty? Date: Have you had a recent EKG? Date: Have you had a stroke? Date: Lung Health Do you smoke currently? How much? For how long Have you smoked in the past and recently quit? Date: Do you have Asthma? Do you use an inhaler regularly? Do you currently have a cold, cough, or respiratory infection? Have you had Tuberculosis or Valley Fever? Date: Do you have COPD, emphysema or bronchitis? Do you use oxygen at home for your COPD or emphysema? Do you have any sinus trouble? General Health Have you had/do you have Cancer of any type? Specify: Have you been tested for HIV? When: Result: Have you been tested for any form of Hepatitis? When: Result: Do you have any bleeding problems or blood disorders such as anemia? Do you have a problem with your thyroid? Do you have GERD (acid reflux) or stomach ulcers? Have you ever had a seizure, seizure disorder or epilepsy? Do you have diabetes? Are you on insulin? Do you have liver disease? Do you have kidney disease? Do you think you may be pregnant or are trying to become pregnant? Are you currently nursing? Social History (For anesthetic reasons, honesty is imperative) Do you take street drugs or diet pills? What type? Do you smoke marijuana? If yes how much/often? Do you drink excessive amounts of alcohol? If yes how much/often? Do you have any medical conditions that we should be aware of? Specify: Dental History Are you experiencing any pain at this time? Do you clench or grind your teeth? Do you have painful, popping, or clicking jaw joints? Are you wearing contact lenses? Are you wearing a removable dental appliance? Have you had any problems with local anesthetic (freezing)? Have you had any serious problems associated with dental work? Specify: Chief Dental Complaint: I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my oral surgeon, or any member of his staff, responsible for any errors or omissions that I may have made in the completion of this form. Patient or Legal Guardian signature: Date:

4 FINANCIAL POLICY Thank you for choosing Palm Valley Oral and Maxillofacial Surgery for your surgical needs. Please carefully read and initial by each statement and sign below. This policy has been put into place to ensure that the financial payments due are recovered which allows us to continue to provide quality surgical care for our patients. 1. I understand if my account is not paid in full within 90 days, a 35% collection/processing fee will be added to any outstanding balance $10 and above. It will be turned over to E-Services collection specialists for further processing. Any balance of $10 and below will remain on the account for future collection. 2. I understand that a $35 service fee will be added for any checks that are returned for any reason and I will be responsible for payment of this fee plus the amount of the returned check. Non sufficient funds checks must be redeemed with cash, money order or cashier s check. 3. I understand that if I am covered by more than one insurance company for any date of service I am to provide this information to Palm Valley Oral and Maxillofacial Surgery at the time of service. If additional insurance information is received at a later time this could result in denied claims due to timely filing limitations and will be applied to the patient s out of pocket responsibility. 4. I understand that most insurance plans have limitations, restrictions, and disallowed treatments. These vary from plan to plan and vary from extremely limited coverage to very generous coverage. Palm Valley Oral and Maxillofacial Surgery does require that you be responsible for knowing any restrictions and/or limitations within your insurance plan. 5. Palm Valley Oral and Maxillofacial Surgery will allow 60 days from the date of filing for my insurance company to process or pay a claim. Arizona law allows insurance companies operating in the state no more than 30 days to process claims. It is my responsibility to provide my insurance company with any requested information needed to process the claim for services. It is also my responsibility to notify Palm Valley Oral and Maxillofacial Surgery if there are any changes in my insurance coverage, residence, or phone number. Ultimately, it is up to ME to know MY insurance benefits. 6. (Initial if applicable) I have been notified that my insurance is out of network and I understand that my visits may not be covered by my insurance. 7. I have read and understand the above financial policy and I agree to abide by its terms. This agreement shall remain in effect for one year from the signature date and/or must be updated with any changes to insurance or demographic information. Printed Name of Patient Date Signature of Patient/Responsible Party Relationship to Patient

5 HIPPA Consent Section A: Patient Giving Consent: Name: Date of Birth: 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 insurance billing ONLY. 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 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 anytime by contacting: Telephone: (623) Fax: (623) Address: 1646 N. Litchfield Rd, Suite 130 Goodyear, AZ Right to Revoke: You will have the right to revoke this consent at anytime by giving us written notice of your revocation submitted to the address listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation and that we may decline to treat you if you revoke this consent. I,, have had full opportunity to read and consider 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 insurance billing. Signature: Date: Patient or Responsible Party You are entitled to a copy of this consent after you sign it I, allow Palm Valley Oral and Maxillofacial Surgery to discuss my treatment, financial obligations and protected healthcare information with the following person: Name: Relationship to Patient Patient Signature: