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Cumberland Surgical Arts and Associates, PLLC - Cumberland Surgical Arts and Associates, PLLC - Patient Form

Patient information

*Prefix

*First Name

Middle Name

*Last Name

*Date of birth

Social Security Number

Email

*Gender

Street Address 1

Street Address 2

Apt.

City

State

Zip

Primary Phone

Alternate Phone (Mobile, work, or home)

Have you ever been a patient of our practice?

Has a family member ever been a patient of our practice?

Who were you referred by?

First Name

Last Name

Preferred Pharmacy Name

Preferred Pharmacy Phone

Upload your Driver's license

Maximum allowed size : 25MB

Upload your insurance card

Maximum allowed size : 25MB

Upload the back your insurance card

Maximum allowed size : 25MB
Guarantor Information

First Name

Last Name

Relative Phone

Date of birth

Social Security Number

Street Address 1

Street Address 2

Apt.

City

State

Zip

Employer/Business Name

Home Phone

Business Phone

Insurance information

General Insurance information

Employed

Marital status

Are you a student?

School Name

Primary Dental Insurance Subscriber

First Name

Last Name

Patients Relationship to Subscriber

Date of birth

Insured Party Gender

Insured Party Phone

Social Security Number

Insured Party Address 1

Insurance Party Address 2

City

State

Zip

Primary Medical Insurance Subscriber

First Name

Last Name

Patients Relationship to Subscriber

Date of birth

Insured Party Gender

Insured Party Phone

Social Security Number

Insured Party Address 1

Insurance Party Address 2

City

State

Zip

Primary Dental Insurance Information

Employer / Business

Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Ins. Company Address 1

Insurance Company Address 2

City

State

Zip

Phone Number

Group Name

Group Number

Health history

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.

What is your reason for visiting our practice?

What is your height? (in.)

What is your weight? (lbs.)

Are you in good health?

Have there been any changes in your general health in the past year?

Are you under the care of a physician?

Have you had any illness, operation or been hospitalized in the past five years?

Do you have unhealed/recurrent injuries or inflamed areas, growths or sore spots in or around your mouth?

Do you have a prosthetic joint/implant?

Have you had a heart valve replacement or vascular graft?

Have you ever had general anesthesia?

Have you, or a family member, had any unusual or serious reactions to general anesthesia?

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

Is there any condition concerning your health that the doctor should be told about?

Do you wish to speak to the doctor privately about anything?

If you are having surgery today, have you had anything to eat or drink in the last 6 (six) hours?

Who is driving you home?

Mobile Phone

Notify of Pick-up status via

Is there a FAMILY history of

Cancer

Diabetes

Heart Disease

Anesthesia Problems

Autism

Health History Cont.
Have you had or do you currently have...

*Rheumatic fever

*Damaged heart valves/mitral valve prolapse

*Heart murmur

*High blood pressure

*Low blood pressure

*Chest pain/ angina

*Heart attack(s)

*Irregular heart beat

*Cardiac pacemaker

*Heart surgery

*Pneumonia, bronchitis or chronic cough

*Asthma

*Hay fever/sinus problems

*Snoring

*Sleep Apnea / CPAP

*Difficult breathing/other lung trouble

*Tuberculosis

*Emphysema

*Do you smoke or vape?

*Do you use marijuana?

*Do you use chewing tobacco?

*Blood transfusion

*Blood disorder such as anemia

*Bruise easily

*Bleeding tendency/ abnormal bleed

*Hepatitis, jaundice, or liver disease

*Infectious mononucleosis

*Gallbladder trouble

*HIV/AIDS

Have you had or do you currently have...

*Fainting spells

*Convulsions/ epilepsy

*Stroke

*Thyroid trouble

*Diabetes

*Low blood sugar

*Kidney trouble

*High cholesterol

*Are you on dialysis?

*Swollen ankles, arthritis or joint disease

*Osteoporosis/ osteopenia

*Osteonecrosis

*Stomach ulcers/ acid reflux

*Contagious diseases

*Sexually transmitted disease

*Problems with the immune system? Possibly from medication/ surgery, etc.

*Delay in healing

*A tumor or growth

*Cancer, radiation therapy or chemotherapy

*Chronic fatigue/ night sweats

*Are you on a diet?

*A history of alcohol abuse

*A history of drug use?

*Contact lenses

*Eye disease/ glaucoma

*Mental health problems/ anxiety/ depression

*Removable dental appliance

*Pain and clicking of jaws when eating

Surgical History

*Tonsillectomy

Year of Surgery:

*Appendectomy

Year of Surgery:

*Ear Tubes

Year of Surgery:

*Angioplasty

Year of Surgery:

*Hysterectomy

Year of Surgery:

*Tubal Ligation

Year of Surgery:

*Bypass Surgery

Year of Surgery:

*Gallbladder Surgery

Year of Surgery:

*Hernia Repair

Year of Surgery:

*Artificial Valve

Year of Surgery:

*Artificial Joint

Year of Surgery:

*Anesthesia Complications

Year of Surgery:

Please list any other surgeries that you have had, that are not listed above.

Pregnancy and Birth Control

Is there a possibility of pregnancy?

Expected delivery date?

Are you nursing?

Are you taking birth control pills?

Date of your last period?

Note: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding other 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 Dr. Lee/Dr. Lilly/ Dr. Griffith/Dr. Porter, or any other member of staff,  responsible for any errors or omissions that I have made in the completion of this form.

*Sign

Date

Medications Allergies
Medications (Are you now taking...)

Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Aggrenox, Pradaxa, Fish oil)

Have you ever taken diet pills

Any natural product, herbal supplement or homeopathic remedy

Are you taking, or have you ever taken bone density meds, RANKL inhibitors or bisphosphonates such as Denosumab, Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Reclast, or Evista in the past 12 years?

Have you ever taken tranquilizers, sleeping pills, anti-depressants and/or narcotics on a regular basis. If yes, please list:

If you are under the care of a physician for pain management, or recovering from drug addiction please select the medication you are currently taking:

Methadone

Suboxone

Oxycodone

Fentanyl

Other

Other Description

Treating Doctor First Name

Treating Doctor Last Name

Are you allergic or had a reaction to:

Local anesthetic (numbing medication)

Penicillin

Other antibiotics

Sulfa Drugs

Sodium pentothal, Valium, or other tranquilizer

Aspirin

Amoxicillin

Codeine or other narcotics

Latex

Soy

Eggs/Yolk

Sulfites

Do you have any known allergies?

Please list any allergies other than drug allergies?

Are you taking any kind of medication, drug, pills?

Please list any other medications or antibiotics you are allergic to.

Medication / Antibiotic Allergy #1

Medication Name

Conclusion
Emergency Contact Details

First Name

Last Name

Home Phone

Mobile Phone

Relationship to Patient

Medical Information Release Form - HIPAA Release Form

Name

Date of Birth

Relationship

.

Name

Date of Birth

Relationship

.

Name

Date of Birth

Relationship

.

.

*Patient (Or Guardian) Signature

*Date

Verification

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 doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.

FEES & PAYMENTS

We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. 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, attorneys fees, and court costs.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.

Release of Information

This signature on file is my authorization for the release of information necessary to process my claim. Reimbursement will go to PT.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.

Authorization for Service

I authorize the doctors of Cumberland Surgical Arts and Associates and designated their staff, to perform an examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x-rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of 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 regarding this notice. I have been provided with the following disclosure information from the practice upon registering; Facility Information, Patient Bill of Rights, Complaint Resolution, Billing Information, Facility Ownership Disclosure, Pain Assessment, and Physician Qualification. I may request a copy of the above listed disclosures at any time.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.

Notice of Privacy Practices

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.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.

COVID-19 Pandemic Dental Treatment

NOTICE AND ACKNOWLEDGEMENT OF RISK FORM - Our goal is to provide a safe environment for our patients and staff, and to advance the safety of our local community. This document provides information we ask you to acknowledge and understand regarding the COVID‐19 virus. The COVID‐19 virus is a serious and highly contagious disease. The World Health Organization has classified it as a pandemic. You could contract COVID‐19 from a variety of sources. Our practice wants to ensure you are aware of the additional risks of contracting COVID‐19 associated with dental care. The COVID‐19 virus has a long incubation period. You or your healthcare providers may have the virus and not show symptoms and yet still be highly contagious. Determining who is infected by COVID‐19 is challenging and complicated due to limited availability for virus testing. Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office. Dental procedures create water spray which is one way the disease is spread. The ultra‐fine nature of the water spray can linger in the air for a long time, allowing for transmission of the COVID‐19 virus to those nearby. You cannot wear a protective mask over your mouth to prevent infection during treatment as your health care providers need access to your mouth to render care. This leaves you vulnerable to COVID‐19 transmission while receiving dental treatment. I confirm that I have read the Notice above and understand and accept that there is an increased risk of contracting the COVID‐19 virus in the dental office or with dental treatment. I understand and accept the additional risk of contracting COVID‐19 from contact at this office. I also acknowledge that I could contract the COVID‐19 virus from outside this office and unrelated to my visit here. I have read and understand the information stated above:

*Sign

Date

Cumberland Surgical Arts and Associates, PLLC Financial Agreement

We strive to provide high quality, cost effective care to our patients. Our first priority is to you, our patient. As we are sure you understand, to continue providing care we must receive prompt payment for the services rendered. Your assistance in seeing that your account is kept current is appreciated!

This office will accept the following methods of payment for services rendered: Discover/Visa/MasterCard/American Express/Debit Cards/Cash/Cashier’s Check. We DO NOT accept personal checks. Responsible parties without insurance coverage agree to pay for services at time of visit. All procedures must be paid in full prior to surgery. We do accept CareCredit financing to assist with the cost of your surgical treatment in limited circumstances. If you would like to utilize CareCredit financing, please discuss this first with our financial counselor to see if your treatment plan meets the criteria. Please understand we do not offer all CareCredit. We do not provide in-house financing or payment plans. This office will not be involved with any third-party liability cases. We do not file with automobile or home owner’s insurance liability policies. Services are to be paid in full by you and you can seek reimbursement from the liability insurance company. We are not a provider for Workers’ Compensation Plans. It is our policy to submit any insufficient funds to the appropriate legal authorities. A $35 charge will be added to your account for each check returned. You agree to pay all costs of collection including attorney fees, collection fees, and contingent fees to collection agencies of not less than 35%, such contingency fee to be added and collected by the collection agency immediately upon your default and our referral of your account to said collection agency. In cases of divorced parents, the parent bringing the child will be deemed responsible for payment. We cannot become involved with personal issues between divorced/separated spouses. It is their responsibility to coordinate payment for surgery and see that payment of the estimated patient portion is paid in full prior to surgery. We will not make another party responsible for the account without their written consent. All patients are charged the same for services rendered. This office does not accept reasonable and customary charge calculations by outside parties, unless this office is a participating provider. Any adjustments/write-offs will be applied upon receipts of payment and EOBs. Patients who do not give 2 business days notice to cancel a surgery or no show for surgery will be billed a $150 No-Show fee. This is not billed to your insurance company and will not be credited towards future appointments. You may not reschedule until this fee is paid. At doctors discretions you may be discharged from the practice. All procedures require a $150 deposit to be paid prior to scheduling. Our treatment coordinator will discuss that with you further when discussing your cost for procedure. This amount will be applied to the overall cost of your procedure. However, if you do not give 2 business days’ notice to cancel surgery or no show for surgery the $150 will be applied to your account. This charge will be applied as the late cancellation/ no show fee and will no longer be applied towards the procedure as stated above. All post-op appointments which are missed (no-show) will be assessed a $10 fee. Missed follow up appointments will be assessed a $50 fee. This also is not billed to your insurance company. If you must cancel your surgical appointment, we require at least 2 business days notice and 1 business day for follow ups and post op appointments. If you do not confirm your surgical appointment with a member of our team (must speak to us) prior to 24 hours (1 business day) before your scheduled surgery your appointment will be cancelled. You will also be charged $150 cancellation/no-show charge.

Patients with Insurance – Please read the additional policies:

The most common misconception concerning insurance is that your policy will cover the total cost of surgical fees charged. Insurance is designed to reduce your out of pocket cost, but usually will not eliminate it entirely. Your portion is due at the time of service. Your surgical treatment is not dictated on what your insurance will cover. Together, your surgeon and you create your treatment plan based on what your current medical and dental needs are. We cannot limit your care to just what is covered by your insurance plan. Every plan is different and each insurance company determines what is covered. Just because a particular service is not covered does NOT mean you do not need it. Insurance will only be filed for plans that we are provided with at the time of service. We will not “back file/retro-file” any claims. You must provide all insurance information at the time of service. You are responsible for filing any claims with insurance plans we were not made aware of. If your insurance policy requires a referral, that must be obtained prior to the appointment. We will not obtain “retro” authorizations for services not authorized in advance by the insurance company. It is the patient’s responsibility to know if their insurance plan requires a referral from their primary care doctor. If no insurance payment has been received within ninety (90) days of service, the patient is fully responsible for payment of the account. Please contact your insurance company to ensure your benefits are paid on your behalf. Any unpaid amount not covered by your insurance must be paid in full by the responsible party no later than 60 days following receipt of the explanation of benefits from your insurance company. Due to increases in postage and mail supplies, Cumberland Surgical Arts and Associates will only send out ONE (1) billing statement per date of service. It is your responsibility to keep your account current and to update us with address changes as they occur. All account balances must be paid within THIRTY (30) days from the date on the statement. If payment has not been made to an account ninety (90) days after receipt of the explanation of benefits, and no contact or appropriate arrangements have been made, the account will be referred to the necessary legal authorities and credit bureau service. Any postage returned because you have failed to provide us with the most current address will be added to your account. Insurance will NOT be filed for cosmetic surgery procedures. If your surgeon determines that your procedure may be considered medically necessary by your insurance company, then we will assist you in filing the appropriate insurance paperwork. Final determination of medical necessity for insurance purposes is made by your insurance company. Insurance coverage will be verified at the time of service. You must provide this office with an insurance card or proof of coverage. If coverage is unable to be verified, you are responsible for all charges incurred. Upon verification of insurance benefits, we will attempt to estimate your portion of fees due. You are responsible for any co insurance amounts prior to surgery. We cannot, by federal law, discount your portion as determined by your insurance company. If there is any other payment on the responsible parties’ part or the insurance company’s part over the charges submitted, we will refund the difference. This takes about 30 days to process. Responsible parties with insurance coverage can either: o File insurance yourself and pay us in full directly the day services are rendered. We will assist you with your paperwork. o Have us file your insurance. We will only file with 2 insurance plans. Filing of any additional plans will be your responsibility. You must have on the day of your appointment: Insurance card with Subscriber’s information Photo ID (We do not file ANY insurance without a photo ID – driver’s license, Military ID) The co-payment and deductible (as applicable) the day services are rendered. Co-payment can vary with insurance plans.

Please read regarding estimate of benefits for surgery:

We are not privileged to all insurance plans limitations and exclusions. You, as the beneficiary of the insurance policy, are responsible for knowing all policy limitations and exclusions. The contract for benefits is between you and your insurance company; our only relationship is with you, the patient. We will prepare an estimate of insurance payment and your responsibility. This is prepared using information provided by your insurance plan’s representative. We only use the information they provide us with, so if the information is not current, inaccurate, or lacking in detail, that will affect the treatment plan estimate we provide you with. Neither we, nor the insurance company, can guarantee the estimated payment amounts. Please understand that the estimate generated is provided as a courtesy. We will assist you in understanding your benefits, but are not responsible for your benefits or what is ultimately paid by your insurance plan. Any discrepancies should be addressed with your insurance company as they make the final determination of benefits provided, not us. You are responsible for verifying that all waiting periods have been satisfied prior to surgery. We cannot be held to the estimate of insurance benefits, as it is only an estimate based on information provided on the day it is generated. Annual maximums, deductibles, and percentages of coverage may be different on the day of surgery based on care received by other practitioners and the medical necessity of the procedure as determined by your insurance company. Your surgeon does not determine medical necessity for your insurance company, but will assist in providing justification for surgery to your insurance company to assist in determination of benefits. You, as the patient, are ultimately responsible for the full amount of the surgical cost. Insurance is filed solely as a courtesy to our patients. Please help us to keep this service available to all patients.

If you have insurance, you must sign below: I authorize release of any information relating to this claim. I understand that I am financially responsible for all costs of treatment. I hereby authorize payment of the medical and/or dental benefits otherwise payable to me directly to the below named entities.

*Sign

Date