MID-ATLANTA ORAL SURGERY! WELCOME TO OUR PRACTICE (Please Print)

Transcription

1 Page 1 of 6 Today s date: Patient s Last name: First name: Middle name: Sex: M F MID-ATLANTA ORAL SURGERY! WELCOME TO OUR PRACTICE (Please Print) PATIENT INFORMATION Mr. Mrs. Miss Ms. Birth Date: Age: Social Security #: Marital Status (Mark one) Single Married Div. Sep. Wid. Street Address: Home Phone: Mobile Phone: P.O. Box: City: State: ZIP code: Chose practice because/referred to practice by (Please check one box): Dr. Insurance Plan Hospital Family Friend Close to home/work Yellow Pages Other RESPONSIBLE PARTY INFORMATION Last name: First name: Mr. Miss Mrs. Ms. Middle name: Sex: Birth Date: Age: Social Security #: M F Marital Status (Mark one) Single Married Div. Sep. Wid. Street Address: Click here to enter text. Home Phone: Mobile Phone: P.O. Box: City: State: ZIP code: DENTAL INSURANCE INFORMATION (Please give your insurance card to the receptionist) Insurance Company Name: Patient s Relationship to Cardholder: Self Spouse Child Other Dependent Primary s Cardholder s Name: Birth Date: Employer: Member/Subscriber ID: MEDICAL INSURANCE INFORMATION (Please give your insurance card to the receptionist) Insurance Company Name: Patient s Relationship to Cardholder: Self Spouse Child Other Dependent Primary s Cardholder s Name: Birth Date: Employer: Member/Subscriber ID:

2 Page 2 of 6 MEDICATION Are you now taking Yes No 201. Any kinds of medication, drug, pills? 202. Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginkgo Biloba)? 203. Have you ever taken diet pills? 204. Any natural product, herbal supplement or homeopathic remedy? 205. Any bone density medications/bisphosphonates (Aredia, Zometa, Fosamax, Actonel)? Notes 206. Have you ever taken tranquilizers, sleeping pills, antidepressants, and/or narcotics on a regular basis? If so, please list: 207. Please list any medications you are currently taking: ALLERGIES Are you allergic to, or had a reaction to Yes No Notes 208. Local anesthetic (numbing med.)? 209. Penicillin? 210. Other antibiotics? 211. Sulfa Drugs? 212. Sodium Pentothal, Valium, or other tranquilizers? 213. Aspirin? 214. Codeine or other narcotics? 215. Other medications? 216. Latex? 217. Soy? 218. Eggs/Yolk? 219. Sulfites? 301. Is there any condition concerning your health that the Doctor should be told about? Yes No (If so, describe) 302. Do you wish to speak to the doctor privately about anything? Yes No Is there a FAMILY HISTORY of: 303. Cancer: Yes No 304. Diabetes: Yes No 305. Heart Disease: Yes No 306. Anesthetic Problems: Yes No 307. IN CASE OF EMERGENCY, CONTACT: Name: Home Tel: Bus. Tel: 308. IS THIS VISIT RELATED TO AN ACCIDENT? Automobile: Yes No Work Related: Yes No Other: Yes No Date of Injury: Insurance company handling this claim: Claim Number: Name of Attorney/Adjustor: Telephone number: THIS SECTION ( ) IS FOR WOMEN ONLY! 401. Is there a possibility of pregnancy: Yes No 402. Expected delivery date: 403. Are you nursing? Yes No 404. Are you taking birth control pills? Yes No Women Note: Antibiotics (Such as Penicillin) may alter the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control Please list any allergies other than drug allergies:

3 Page 3 of 6 HEALTH HISTORY Circle/ Mark Appropriate answer (leave blank if you do not understand) Yes No Is your general health good? Yes No Has there been a change in your health within the last year Yes No Have you been hospitalized or had a serious illness within the last (3) years? If yes, why? Yes No Are you being treated by a physician now? If yes, why? Yes No Have you had problems with prior dental treatment? Yes No Are you in pain now? Yes No Chest Pain Yes No Dizziness Yes No Swollen ankles? Yes No Ringing in ears? Yes No Shortness of breath? Yes No Headaches? Yes No Recent weight loss, fever, or night sweats Yes No Fainting spells? Yes No Persistent cough, coughing up blood? Yes No Blurred vision? Yes No Bleeding problems, or bruising easily? Yes No Seizures? Yes No Sinus problems? Yes No Excessive thirst? Yes No Diarrhea, constipation, blood in stool? Yes No Frequent urination? Yes No Frequent vomiting, nausea? Yes No Dry mouth? Yes No Difficulty swallowing? Yes No Joint pain, stiffness? Yes No Heart disease, heart attacks, or heart defects? Yes No AIDS Yes No Heart murmurs? Yes No Tumors, cancer? Yes No Rheumatic fever? Yes No Arthritis? Yes No Stroke, hardening of arteries? Yes No Eye diseases? Yes No High blood pressure? Yes No Skin diseases? Yes No Asthma, or any lung disease(s)? Yes No Anemia? Yes No Hepatitis, or any liver disease(s)? Yes No VD (syphilis or gonorrhea)? Yes No Stomach problems, ulcers? Yes No Kidney, bladder disease? Yes No HIV? Yes No Thyroid, adrenal disease? Yes No Family history of tumors, or heart problems? Yes No Diabetes? Yes No Psychiatric care? Yes No Hospitalization? Yes No Radiation treatments? Yes No Blood transfusions? Yes No Chemotherapy? Yes No Surgeries? Yes No Prosthetic heart valve? Yes No Pacemaker? Yes No Artificial joint(s)? Yes No Contact lenses? Yes No Do you drink alcohol? Yes No Are you taking any recreational drugs? Yes No Women ONLY: Are you pregnant or nursing? Yes No Women ONLY: Are you taking birth control?

4 Page 4 of 6 I certify I have read and I understand the questions 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 surgeon, or any other member of his/her staff, responsible for any error or omissions that I have made in the completion of this form. FEES AND PAYMENTS We make every effort to keep the cost of your oral surgery procedure down. If you have any dental and/or medical insurance, we will be glad to fill out the proper forms but please complete the identifying information on Page 1. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute of payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorney s fees and court costs. This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me. AUTHORIZATION I authorize my surgeon and his/her designated staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking all x-rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment. I hereby acknowledge that a copy of this office s. Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

5 Page 5 of 6 We appreciate the trust you have placed in us! Payment is expected at the time service is rendered. We accept Cash, Debit, and most Credit Cards. INSURANCE: Professional services are rendered and charged to you, not the insurance company. Please understand that payment for services is your responsibility. All deductibles and fee amounts not covered by insurance are due at the time of treatment unless written financial arrangements are made with the Office Manager prior to starting treatment. Our office will not enter a dispute with an insurance company over your claim. This is your responsibility and obligation. Our Central Billing Department will file your claim one time. You will receive a statement every month your account shows a balance due. If at the end of 60 days, your insurance company has not paid, you are responsible for the entire balance. Upon request, we will supply you with a copy of the claim, so you can resubmit it if necessary. To honor any insurance benefits, you must provide insurance identification (i.e. insurance cards, completed claim forms, benefit books, etc.), and we must be able to verify the current benefits available with each visit to our office. Insurance negotiated fees and reimbursements may represent an agreed-to-fee schedule with your Insurance provider that is different from our Usual and Customary Fees and are part of your Insurance benefit package. The amounts you are charged or reimbursed are subject to change at the discretion of your insurance company. We always provide the most recent fee schedules and reimbursement information available. Your portion can and may change based upon their actions. COORDINATING BENEFITS: If you have two forms of benefit coverage, we will consider your coverage as primary and your spouse s coverage as secondary. If your dependent has two plans, we will apply the Insurance Industry Standard Birthday Rule to determine the primary and secondary coverage. If you have two managed care plans you must choose one of the two plans you would like to use. We are unable to coordinate benefits for more than one managed care plan per patient. Also, we are unable to coordinate benefits with multiple discount plans. If you belong to a Managed Care Insurance Plan (HMO or DMO), all applicable fees are due at the time of treatment. Please refer to your co-payment schedule for applicable fees. EXTENDED PAYMENT PLAN: A third-party organization provides loans to patients for dental treatment. A patient must qualify for this type of arrangement. Applications are available in this office. Please feel free to ask for one. BROKEN APPOINTMENT POLICY: Please consider your scheduled appointments carefully. We ask for a 24-hour notice of cancellation. If we do not receive a 24 hours notice, we may charge you for the scheduled time. This cannot be charged to you Insurance Company. If you repeatedly miss scheduled appointments, you may be asked to pursue treatment on non-scheduled time, as available. $25.00 OFFICE FEES: If you present a check for insufficient funds, or place a stop-payment on an issued check, you will be charged a $35.00 fee for processing. If you have any questions regarding your account, please do not hesitate to ask. I have read and understand the statement outlined above.

6 Page 6 of 6 TRACY E. DILLON, DDS Oral & Maxillofacial Surgeon Mid Atlanta Oral & Maxillofacial Surgery I (Please Print) Acknowledge receiving a copy of the NOTICE OF PRIVACY FOR PROTECTED HEALTH INFORMATION, HIPPA Revision The purpose of this notice is to inform you about your rights and how protected health information collected about you may be used and disclosed. Signed: (Please return upon signing so this copy may be placed in your medical chart) E EE S EE E S I E L i l A Smile Last a Lifetime