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Oral and Maxillofacial Surgery Specialist of CO Springs - 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?

Dentist Name

First Name

Last Name

Orthodontist Name

First Name

Last Name

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
Nearest relative not living with you

First Name

Last Name

Relative Phone

Personal Payment Type

Who will be responsible for your account?

Account 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

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 Dental Insurance Company

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

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 Medical Insurance Company

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

Do you have secondary dental insurance?

Secondary 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

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.

If you are a previous patient to our practice, have you had any changes to your medical history in the past year?

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?

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

History of Surgery

*Please list any surgeries you have had. (If none, type N/A)

Have you had or do you currently have...

*History of heart problems?

*Pneumonia, bronchitis or chronic cough

*Asthma

*Hay fever/sinus problems

*Sleep Apnea / CPAP

*Difficult breathing/other lung disease

*Do you smoke or vape?

*Do you use marijuana?

*Do you use chewing tobacco?

*Blood disorder such as anemia

*Bruise easily

*Bleeding tendency/ abnormal bleed

*Hepatitis, jaundice, or liver disease

Have you had or do you currently have...

*Fainting spells

*Convulsions/ epilepsy

*Stroke

*Thyroid trouble

*Diabetes

*Kidney trouble

*Swollen ankles, arthritis or joint disease

*Osteoporosis/ osteopenia

*Stomach ulcers/ acid reflux

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

*A tumor or growth

*Cancer, radiation therapy or chemotherapy

*A history of alcohol abuse

*A history of drug use?

*Contact lenses

*Eye disease/ glaucoma

*Mental health problems/ anxiety/ depression

*Pain and clicking of jaws when eating

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.

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

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

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?

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

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

Are you allergic or had a reaction to:

Local anesthetic (numbing medication)

Penicillin

Other antibiotics

Sulfa Drugs

Aspirin

Amoxicillin

Codeine or other narcotics

Latex

Soy

Eggs/Yolk

Do you have any known allergies?

Please list any allergies other than drug allergies?

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

ACKNOWLEDGEMENT

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. These terms remain in effect throughout my treatment with OMS Specialists (OMSS) and apply to all services rendered. By signing below, I acknowledge that I have read, understand, and accept these policies.

*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, INSURANCE, AND PAYMENT RESPONSIBILITIES

OMS Specialists (OMSS) is committed to providing high-quality surgical care at the most reasonable cost. We are happy to provide a pre-surgical fee estimate upon request. However, please understand that insurance coverage varies and rarely covers the full cost of surgical procedures. Insurance is designed to help reduce your out-of-pocket expenses but does not eliminate them entirely.

· Understanding Your Coverage- It is my responsibility to review and understand my insurance policy, including deductibles, co-pays, annual maximums, and coverage limitations. OMSS will submit claims on my behalf to my dental and medical insurance companies as a courtesy, but this does not guarantee coverage or payment for my procedure.

· Patient Financial Responsibility- I am responsible for all costs not covered by my insurance, including deductibles, co-payments, and any fees exceeding my plan’s annual maximum. Payment of my estimated financial responsibility is due at the time of service.

· Claim Processing & Assistance- If my insurance provider delays claim processing, the team at OMSS may request my assistance to facilitate resolution. I understand that any overpayments received will be refunded to the appropriate party, which may be the patient, guarantor, or insurance company.

· Unpaid Balances & Late Fees- If a balance remains after insurance processing, a statement will be sent to me. Unpaid balances over 30 days will incur a 1.5% finance charge per month.

· Collections & Legal Fees- Accounts sent to collections are subject to additional charges, rebilling fees, including up to 30% of the outstanding balance in collection agency fees. If legal action is required, I will also be responsible for any court costs, filing fees, and attorney fees.

· Returned Check Policy- A $25 fee will be charged for checks returned due to insufficient funds.

· Outside Laboratory Fees- Some procedures require the services of outside laboratories (i.e. CBCT scans, biopsy analysis). These fees are separate from my surgical costs and will be billed directly to me by the laboratory.

*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 AND RELEASE OF INFORMATION

· Notice of Privacy Practices- I hereby acknowledge that a copy of OMSS’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.

· Authorization for Information Disclosure- OMSS submits insurance claims electronically unless otherwise requested. By receiving treatment, I authorize OMSS to share necessary health information with my insurance company, claim administrators, and consulting healthcare professionals for the purpose of evaluating and processing claims.

· Insurance Payments- I authorize direct payment of insurance benefits to OMSS for services provided.

· Appointment Messages- I permit messages to be left on my phone and / or mobile phone concerning my appointment.

*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.

CANCELLATION POLICY

Our surgical team carefully prepares for each appointment, reserving dedicated time and resources to provide you with the highest level of care. We require a minimum of 48 hours’ notice to cancel or reschedule an appointment. Cancellations made with less than 48 hours’ notice, as well as missed appointments (no-shows), will result in a $200 fee. While we understand that Colorado weather can be unpredictable, our office closely monitors conditions and remains open whenever it is safe to do so; we ask that patients plan accordingly.

If you need to cancel or reschedule your appointment, please call (719) 590-1500 during regular business hours or leave a voicemail after hours. We recognize that true emergencies may arise and will review these situations on a case-by-case basis. Thank you for your understanding and partnership in helping us maintain an efficient schedule and provide exceptional care to all patients.

*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.

MEDICARE BENEFICIARY AGREEMENT/Medicare Private Contract Acknowledgment

I acknowledge that Dr. Ronald Thoman (NPI 1609977834) and Dr. Cree Kofford (NPI 1568856177) are opted out of Medicare. The opt-out effective dates for both Dr. Ronald Thoman and Dr. Cree Kofford are July 17, 2025, through July 16, 2027. I understand my right to seek Medicare-covered services from non-opt-out providers and that this contract does not apply to other practitioners. Neither Dr. Thoman or Kofford are excluded from participating in Medicare Part B under §§1128, 1156 or 1892 of the Act.

As a Medicare beneficiary:

· I accept full financial responsibility for all services provided by Drs. Thoman and Kofford.

· I understand that Medicare limits do not apply to their charges.

· I agree not to submit any claims to Medicare, nor can I request the practice to submit a claim on my behalf.

· I acknowledge that Medicare will not cover these services and that Medigap and other supplemental plans may also refuse payment.

This contract cannot be signed during an emergency or urgent care situation, except as permitted by Medicare guidelines (3044.28 of the Medicare Carriers Manual).

*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.