general dentist: dr. elcome : dr. dr. to …...we at foothills oral & maxillofacial surgery are...

Date: Name: Nickname:

Soc. Sec.#: Birthdate: Age: E-mail:

Sex: Male Female Marital Status: Single Married Divorced Separated Widowed

Address: City: State: Zip:

Home Phone: Cell Phone: Driver’s License #:

Employer: Business Phone: Full Time Part Time Retired

In case of emergency, who should we contact? Phone:

Nearest relative not living with you: Phone:

Have you ever been a patient of our practice? Yes No Payment Type: Cash Check Credit Card

Name (First, Last): SSN#: DOB: Age: Phone:

Address: City: State: Zip:

Employer: Business Phone:

Have we seen any other family member?

General Dentist: DR.

Referred by: DR.

Medical Doctor: DR.

(First) (Initial) (Last)

PRIMARY DENTAL INSURANCE SECONDARY DENTAL INSURANCE

(First) (Last)

PATIENT INFORMATION

(First) (Last)

(First) (Last)

WHO WILL BE RESPONSIBLE FOR YOUR ACCOUNT?

PRIMARY MEDICAL INSURANCE SECONDARY MEDICAL INSURANCE

Name of Insured Party: Relation: Phone: SSN #: DOB: Address: City: State: Zip: Employer: Bus. Phone: Business Address: City: State: Zip: Ins. Co. Name: Ins. Co. Address: City: State: Zip: Subscriber ID #: Group #:

ELCOME W TO FOOTHILLS ORAL & MAXILLOFACIAL SURGERY



Self Spouse Father Mother Other:


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LIST ANY ALLERGIES (MEDICINES, LATEX, TAPE, FOODS)

HEALTH HISTORY

DO YOU CURRENTLY HAVE OR HAVE YOU EVER HAD:

Rheumatic Fever or Rheumatic Heart Disease? (If answered “YES”, please circle which condition)

YES NO

Damaged Heart Valves/ Mitral Valve Prolapse? (If answered “YES”, please circle which condition)

YES NO

Heart Murmur? YES NO

High Blood Pressure? YES NO

Low Blood Pressure? YES NO

Chest Pain / Angina? YES NO

Heart Attack(s)? Stroke(s)? (If answered “YES”, please circle which condition)

YES NO

Irregular Heartbeat / Arrhythmia? (If answered “YES”, please circle which condition)

YES NO

Cardiac Pacemaker? YES NO

Heart Surgery? YES NO

Lung disease (Bronchitis, Chronic Cough, Emphysema, COPD, Asthma)? (If answered “YES”, please circle which condition)

YES NO

Snoring / Sleep Apnea? (If answered “YES”, please circle which condition)

YES NO

Blood Disorder (Anemia, Blood Transfusions)? (If yes, please circle which condition)

YES NO

Do you bruise easily? YES NO

Bleeding Tendency / Abnormal Bleeding? (If answered “YES”, please circle which condition)

YES NO

Liver Disease (Jaundice, Hepatitis- Type: )? YES NO

Seizures, Convulsions, Fainting / Dizziness, Epilepsy? (If answered “YES”, please circle which condition)

YES NO

Radiation Therapy / Chemotherapy? YES NO

Any disease, medication, surgery, or transplant operation that has depressed your immune system?

YES NO

Diabetes? Type: Oral Medications: Injections: YES NO

Kidney Disease? YES NO

Are you on Dialysis? YES NO

Swelling of Feet/Ankles, Arthritis / Rheumatism or Joint Disease? (If answered “YES”, please circle which condition)

YES NO

Stomach Ulcers or Colitis? (If answered “YES”, please circle which condition)

YES NO

Sexually Transmitted Disease (HIV, AIDS, Herpes)? (If answered “YES”, please circle which condition)

YES NO

Do you smoke? YES NO

Do you use alcohol, chewing tobacco, or other drugs? YES NO

History of Drug Abuse? YES NO

History of Alcohol Abuse? YES NO

Mental Health Problems? YES NO

Jaw Pain / Clicking When Eating, Difficulty Opening Mouth, Grind/Clench Teeth? (If answered “YES”, please circle which condition)

YES NO

Malignant Hyperthermia? YES NO

Taking Any Natural Products, Herbal Supplements, or Homeopathic Remedy?

YES NO

Are you taking any bone density medications/ bisphosphonates (Aredia, Zometa, Fosamax, Actonel)?

YES NO

Have you ever taken tranquilizers, sleeping pills, antidepressants, and/or narcotics on a regular basis? If so, please list:

To our patients: Although oral surgeons primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking, could have an important interrelationship with the care, that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

1. Are you in good health?.............................................................................................................. Yes No 2. Has there been any changes in your general health in the past year?................................... Yes No 3. Are you currently under the care of a physician?..................................................................... Yes No

a. If so, what are you being treated for? b. Date of last visit:

4. Are you currently being treated by a pain clinic?...................................................................... Yes No a. If checked “Yes”, please complete the following:

i. Name of Pain Clinic: Physicians Name: Bus. Phone: ii. Business Address: City: State: Zip:

5. Have you had any serious illnesses, operations or been hospitalized in the past five years?.............................................................................................................................

a. If so, please describe: 6. Do you have unhealed/recurrent injuries or inflamed areas, growths, or sore spots

in or around your mouth?............................................................................................................ Yes No a. If so, where?

7. Do you have a prosthetic joint/ implant?.................................................................................... Yes No a. If so, please describe where:

8. Have you had a heart valve replacement or vascular graft?.................................................... Yes No

PLEASE LIST ANY MEDICATIONS YOU ARE CURRENTLY TAKING

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Patient Name: Height: Weight: Date:

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HEALTH HISTORY UPDATE: (Since your last visit)

PATIENT HIPAA RELEASE

It is the policy of our office to protect all of your private health information. There are, however, times when it may become necessary for us to discuss your treatment, post-operative treatment, or appointments with someone other than yourself.

The Doctors and Staff of Foothills Oral and Maxillofacial Surgery may release information related to my health to the following individuals:

NAME: RELATIONSHIP: PHONE #:




May we leave a detailed message on your answering machine? Yes No

FOR WOMEN ONLY:

Is there a possibility of pregnancy? YES NO

Are you nursing? YES NO

Are you taking birth control pills? YES NO

Expected Delivery Date?

*Please Note: Antibiotics may alter the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control.

I certify that 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 members of his / her staff, responsible for any errors or

omissions that I have made in the completion of this form.

Signature of patient: Reviewed by: Date: (Parent/Guardian if minor)

Date:

Have there been any changes to your health history? YES NO

If so, please list all changes:

Signature of patient: Update Reviewed by: (or Guardian)

Date:




Date:




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Patient Name: Date:

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FOOTHILLS ORAL & MAXILLOFACIAL SURGERY OUR OFFICE FINANCIAL POLICY

You will find our entire staff is dedicated to helping you improve your dental health as quickly as possible. Every effort will be made to make your visit as comfortable and pleasant as possible. We know that understanding our financial policy is an essential element of your care and treatment. To promote a long-term mutually satisfying relationship, we have

outlined our office policy regarding treatment, insurance, appointments and fees.

Please read the information below carefully and ask any questions you may have with our staff.

1. FEES & PAYMENTS: a. Payment is due in full at time of services. We accept cash, personal checks, Mastercard, Visa, Discover, American Express and Care Credit. b. When insurance applies, it is our policy to collect your initial responsibility estimated by your insurance company on day of service. c. Patients who wish to withhold their Social Security Number will be treated on a cash basis only. d. You fully understand and agree that you are responsible for the payment of this account. All accounts over 90 days are subject to a 1% monthly service charge. You

understand if this balance is not paid in full within a reasonable amount of time, (90 days or less), FOMS has the right to take legal action. In the event this account is involved in litigation you expressly waive any objection to venue and set venue may be Blount County, Tennessee. You understand that you will be responsible for additional court and/or attorney fees incurred in the court process.

2. INSURANCE: a. Insurance claims are submitted for our patients as a courtesy. Our services are provided to the patient, not the insurance company. b. Adult children on their parent’s insurance will require a parent’s signature to file with insurance. c. The patient is responsible for providing their current, correct insurance information (Subscriber ID#, DOB, SSN, Employer) and must furnish their insurance card and

driver’s license upon request. d. Patients without proper insurance identification will be considered private pay and will be responsible for their balance on the day of service e. The patient is responsible for full payment of their account, regardless of the status of the insurance claim. In the event that we receive a denial or no response from

your insurance company, we will bill you directly. f. We will not be held responsible for any insurance change we are not aware of. g. In the event your health plan determines a service to be "not covered" you will be responsible for the complete charge. In this case, we will bill you directly. Payment

is due upon receipt of that statement and should be remitted to the address on the statement. h. We will expect you to begin making “good faith” payments in the event your insurance processing goes over 90 days due to incorrect billing information given to us

on the day of service. i. It is your responsibility to know the coverage and limitations of your dental plan (some plans have a $1,000.00 max. and some may have $1500 - $2000 max. per

year). If you are not satisfied with the payment or denial of your claim, you will need to contact your insurance company directly. j. Pre-Authorization: Some benefit plans require pre-authorization and a specialist referral form from the primary care physician or general dentist. It is your responsibility

to know your insurance requirements. It will be helpful for you to call your insurance company prior to your appointment day to determine if you need any prior authorization.

3. TREATMENT ESTIMATE:

a. We at Foothills Oral & Maxillofacial Surgery are providing you with an estimate for today’s services; however, this is only an estimate of your co-pays and deductible for this procedure. Per your insurance company, this is not a guarantee of coverage. We will make every attempt to verify coverage whenever possible, however insurance verification is no guarantee of payment. We need you to be aware that after your insurance has processed your claim, you may or may not owe a balance.

i. Not all procedures are paid at the same percentage. ii. Some procedures may not be covered. iii. You may have a waiting period. iv. Your insurance plan may have a yearly maximum benefit. v. You may have given incorrect insurance information.

b. After your insurance has completed your claim, if there has been an overpayment made by the patient, we will issue a refund check to be mailed at the end of each month.

4. MISSED APPOINTMENTS: When we schedule your appointment, the time is reserved exclusively for you. When you fail to notify us of your inability to keep an appointment,

another patient in need of oral surgery is unable to receive treatment. We request that you give us at least 48 hours’ notice when you realize that you cannot keep an appointment. When the requested notice is not given, a fee may be charged.

5. MINORS: The parent, guardian, or another adult accompanying a minor are responsible for full payment. For unaccompanied minors, nonemergency treatment will be denied

unless charges have been pre-authorized to an approved credit plan, Mastercard, Visa, Discover, American Express or Care Credit.

6. PERSONAL INJURY CASES: This office does not accept liens nor bill auto accident, liability or lawsuit related cases. The patient is responsible for payment at the time

services are provided.

7. WORKMANS COMPENSATION: We require the necessary insurance billing information and employer authorization. Without proper information, you will be responsible.

8. DIVORCED PARENTS: We will be glad to bill the responsible parent for your child’s account. However, both parents are responsible for a minor child’s bill and both parents

will be held accountable. We are not a party to your divorce decree. It will be up to the parents to determine “who owes what”.

We make every effort to keep down the cost of your oral surgical care. You can help by paying upon completion of each visit. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. 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 this form. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for 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.

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.

Signature of patient: (Parent or Guardian if minor) X Date:

Signature of patient: (Parent or Guardian if minor) X Date:

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general dentist: dr. elcome : dr. dr. to …...we at foothills oral & maxillofacial surgery are...

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