Patient Data Record

PATIENT DATA RECORD

WELCOME TO OUR OFFICE Date ______

Patient Name ______Birthdate ______Sex M F

Address ______Last 4 Digits of SS# ______

City ______State ______Zip ______

Home Telephone #______Work Telephone #______Cell#______

Please circle one: minor student single married divorced widowed

Spouse or parent's name ______

Referring Dentist or Physician ______

Emergency Contact______Daytime phone #______Relationship______

RESPONSIBLE PARTY

Name of person responsible for this account ______Relationship_____

Address ______

Employer ______Drivers License # ______

DENTAL INSURANCE INFORMATION (Please show insurance card(s) to receptionist)

Dental Insurance #1

Name of Insured ______Relationship to patient ______

Birthdate ______Policy/ID# ______

Employer ______

Insurance Co. ______

Insurance Co. Address ______

Dental Insurance #2

Name of Insured ______Relationship to patient ______

Birthdate ______Policy/ID#______

Name of Employer ______

Insurance Co. ______

Insurance Co. Address ______

PLEASE SEE PAGE 2 OF THIS FORM TO LIST MEDICAL INSURANCE POLICIES

ASSIGNMENT OF BENEFITS

I authorize payment of benefits to Oral and Maxillofacial Surgery Services, P.L.C. for all services rendered. I understand that I am financially responsible for all charges whether they are paid by my insurance. There will be a service charge of 1.5% per month on all unpaid balances over 60 days old. I hereby authorize said assignee to release all information needed to secure payment. A photocopy of this is considered as valid as the original.

______

Date Responsible Party Signature

PATIENT DATA RECORD

MEDICAL INSURANCE INFORMATION (Please show insurance card(s) to receptionist)

Medical Insurance #1

Name of Insured ______Relationship to patient ______

Birthdate ______Policy/ID# ______

Employer ______

Insurance Co. ______

Insurance Co. Address ______

Medical Insurance #2

Name of Insured ______Relationship to patient ______

Birthdate ______Policy/ID# ______

Name of Employer ______

Insurance Co. ______

Insurance Co. Address ______

Patient Acknowledgement and Consent Form

Please sign this form below to consent to our disclosures of your information that we deem necessary in order to provide you with proper treatment.

I acknowledge that I have received a copy of this office’s Notice of Privacy Practice Form.

I consent to your disclosures of my information, which you deem are necessary in connection with my treatment.

______

Patient Signature or Parent/Legal Guardian Patient Name (please print) or

Parent/Legal Guardian

Date:______

I authorize my physician and/or administrative and clinical staff to disclose the following protected health information to:

Name: ______Relationship to Patient ______

Select the Protected Health Information to be used or disclosed tothe above listed individual(s) from the list below:

Medical Care/ Treatment: Yes ___ No ___
Billing Information: Yes ___ No ___

This authorization shall be in force and does not expire until it is revoked in writing. I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the practice’s Privacy Contact. I understand that a revocation is not effective to the extent that my physician has relied on the use or disclosure of the protected health information or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

MEDICAL HISTORY

Name______Birthdate______Age______Sex M or F

Home phone______Daytime phone (work)______

Physician______Height______Weight______

Physician Phone______Physician Address______

Dentist______Referred by______

PLEASE ANSWER EACH QUESTION (Give details for Yes answers under the remarks section)

1. Have you been under the care of a physician during the last 2 years?YN

2. Has there been a change in your general health during the past year?YN

3. Have you ever been admitted to a hospital or had an operation?YN

4. Have you ever had a reaction from anesthetics?YN

5. Have you ever had any excessive bleeding from injury, tooth extraction, etc?YN

6. Have you ever had any pain, noise (clicking, popping) or discomfort in your jaw or jaw joints?YN

7. Have you had any other illness or condition other than the common cold or flu?YN

8. Can you walk up a flight of stairs without stopping?YN

9. Have you ever had osteoporosis or take medication for osteoporosis?YN

If yes, which medication do you take?______

10. (WOMEN) Are you pregnant or do you think you are pregnant?YN

Are you nursing?YN

Have you ever had any of the following problems: (Please circle Yes or No for all questions)

anemia/blood problemsYNstrokeYNseizures/epilepsyYN

embolism/blood clotYNheart murmurYNthyroid diseaseYN

blood transfusionYNpacemakerYNglaucomaYN

current/recent coldYNheart valve diseaseYNstomach ulcersYN

sinus trouble YNrheumatic feverYNkidney/liver diseaseYN

bronchitisYNchest pain/anginaYNhepatitis/jaundiceYN

emphysemaYNheart attackYNimmune disorderYN

asthmaYNheart problemsYNMRSAYN

chronic coughYNjoint replacementYNcancer or tumorYN

pneumoniaYNorthopedic plates/pinsYNradiation/chemotherapyYN

tuberculosisYNhigh/low blood pressureYNmental health problemsYN

shortness of breathYNdiabetesYNanxiety/nervous disorderYN

fainting/dizzinessYNlow blood sugarYNosteoporosisYN

See Page Two

(other side)

LIST MEDICATIONS that you are currently taking:______

______

Do you have an ALLERGY to any medicines, foods, environmental, latex? If yes, please list:

______

REMARKS (please list hospital admissions / operations and year: for example, 1985 – tonsillectomy)______

______

Is there anything you wish to discuss in private with the doctor? Yes No

SOCIAL HISTORY

Occupation:______Employer:______

Special diet:______Exercise (specify type and frequency)______

Alcohol ConsumptionYNIllicit Drug/Substance UseYN

Tobacco Use – If yes, circle typeYNCigarettes Chewing Tobacco Pipe Cigars

If history of smoking, when did you quit?______

FAMILY HISTORY (please circle and complete all that apply)

AgeMajor Health Issues / Cause of Death

Father_____LivingDeceased______

Mother_____LivingDeceased______

Brother(s)_____LivingDeceased______

Sister(s)_____LivingDeceased______

Child(ren)_____LivingDeceased______

SIGNATURE:______Date:______

(Patient, Parent or Legal Guardian)

INSURANCE AUTHORIZATION

(INCLUDING WORKERS’ COMPENSATION AND AUTO CARRIERS)

I hereby assign all dental, medical, and/or surgical benefits, including major medical benefits, to which I am entitled. I hereby authorize and direct my insurance carrier(s), including: Medicare, private insurance, and any other health/medical plan, to issue payment directly to Oral & Maxillofacial Surgery Services, P.L.C., for dental/medical services provided to me or my dependents regardless of my insurance benefits, if any. I understand that I am financially responsible for any balance not covered by my insurance carrier. I understand that if services are rejected by Workers’ Compensation as non-related or in dispute of a work related injury, I am financially responsible for these charges.

I authorize the provider/supplier to initiate a complaint to the Insurance Commissioner for any reason on my behalf. A copy of this signature is as valid as the original.

Signed:______Date: ______

FOR OUR MEDICARE PATIENTS ONLY

NAME OF BENEFICIARY: ______

MEDICARENO.: ______

I request that payment of authorized Medicare benefits be made to me or on my behalf to Oral & Maxillofacial Surgery Services, P.L.C., for any services furnished to me by that provider/supplier. I authorize any holder of my medical information to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services.

I hereby authorize Medicare to furnish to the above named provider/supplier any information regarding my Medicare claims under Title XVII of the Social Security Act. This authorization is in effect until I choose to revoke it.

Signed:______Date: ______

***************************************************

Medicare Beneficiary Agreement

I have been notified by this office that they believe, in my case, Medicare is likely to deny payment for the services identified. I understand that I have the right to decide whether or not to have the procedure(s) performed. By signing this agreement, I have decided to have the procedure(s) performed and if Medicare denies payment, I agree to be personally and fully responsible for the payment.

Signed: ______Date: ______

Please sign this form below to consent to our disclosures of your information that we deem necessary in order to provide you with proper treatment.

I specifically authorize Oral & Maxillofacial Surgery Services, PLCto use and disclose verbally, by mail, fax or unencrypted email, the following types of super-confidential information as stated in the Notice of Privacy Practices (initial where appropriate):

___HIV records (including HIV test results) and sexually transmissible diseases

___Alcohol and substance abuse diagnosis and treatment records

___Psychotherapy records

___Any of the above information listed on the health history form completed for this office

___Not Applicable

I acknowledge that I have received a copy of this office’s Notice of Privacy Practice Form.

I consent to your disclosures of my information, which you deem are necessary in connection with my treatment.

______

Patient Signature or Parent/Legal Guardian Patient Name (please print) or

Parent/Legal Guardian

Date:______