DSNForms

Alaska Center for Oral & Facial Surgery - Patient Form

Patient information

*First Name

Middle initial

Nickname

*Last Name

*Gender

*Date of birth

Age

Social Security Number

Street Address

City

State

Zip

PO Box or Apt #

Email

Home Phone

Alternate Phone (Mobile, work, or home)

Marital Status

If Student

Name of School

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

How did you choose our practice?

Dentist Name

Orthodontist Name

Primary Physician Name

Referring Doctor Name

Guarantor Information

If you are under 18 or a parent will be financially responsible for your account, please complete the following information:

First Name

Last Name

Relative Phone

Date of birth

Social Security Number

Address

Phone Number

Who came with you to the appointment today?

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
Primary Dental Insurance

Ins. Company Name

Ins. Company Address

City

State

Zip

Phone Number

Policy I.D. Number

Insured First Name

Insured Last Name

Insured Employer / Business

Insured Date of birth

Insured Social Security Number

Patients Relationship to Subscriber

Secondary Dental Insurance

Ins. Company Name

Ins. Company Address

State

City

Zip

Phone Number

Policy I.D. Number

Insured First Name

Insured Last Name

Insured Employer / Business

Insured Date of birth

Insured Social Security Number

Patients Relationship to Subscriber

Primary Medical Insurance

Ins. Company Name

Ins. Company Address

City

State

Zip

Phone Number

Policy I.D. Number

Insured First Name

Insured Last Name

Insured Employer / Business

Insured Date of birth

Insured Social Security Number

Patients Relationship to Subscriber

Secondary Medical Insurance

Ins. Company Name

Ins. Company Address

City

State

Zip

Phone Number

Policy I.D. Number

Insured First Name

Insured Last Name

Insured Employer / Business

Insured Date of birth

Insured Social Security Number

Patients Relationship to Subscriber

I authorize Alaska Center for Oral & Facial Surgery to release any information for insurance purposes. I hereby authorize payment directly to Alaska Center for Oral & Facial Surgery. I certify that the information on this form is correct. I understand that I am responsible for any balance on this account, even if I have medical and/or dental coverage.

*SIGNATURE (of patient or legal guardian)

*Date

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 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?

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

Past Surgical History

Name of procedure and year performed

Procedure

Year Performed

Procedure

Year Performed

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 disorder such as anemia

*Bleeding tendency/ abnormal bleed

*Hepatitis, jaundice, or liver disease

*Infectious mononucleosis

*Gallbladder trouble

Have you had or do you currently have...

*Convulsions/ epilepsy

*Stroke

*Thyroid trouble

*Diabetes

*Low blood sugar

*Kidney trouble

*High cholesterol

*Swollen ankles, arthritis or joint disease

*Osteoporosis/ osteopenia

*Stomach ulcers/ acid reflux

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

*Delay in healing

*Cancer, radiation therapy or chemotherapy

*A history of alcohol abuse

*A history of drug use?

*Eye disease/ glaucoma

*Mental health problems/ anxiety/ depression

*Pain and clicking of jaws when eating

Pharmacy Details

Pharmacy Name

Pharmacy Phone Number

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?

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

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

Allergies

Please list any allergies you have below.

Allergy #1

Office Financial Policy

We believe that our patients expect and deserve the highest quality care at a reasonable cost. Alaska Center for Oral + Facial Surgery (AOFS) shares the concern of our patients about the increasing cost of dental and medical care. Our fees are comparable to the usual and customary charges made by Oral and Maxillofacial Surgeons in the area. These charges are based on doctor’s costs, time, and skill involved. You will be given a written estimate of the charges before treatment has started.

NOTE: AOFS is not a contracted, in-network, preferred provider with any insurance plans. You may incur out of network charges.

PATIENTS WITH INSURANCE: Alaska Center for Oral +Facial Surgery is committed to helping you understand your insurance benefits. Because insurance policies vary, we can only estimate your coverage in good faith but cannot guarantee coverage due to the complexities of insurance contracts. Your estimated patient portion must be paid at the time of service. Final determination will be made by the insurance company once the claim has been processed. As a service to our patients, we will bill insurance companies for services and allow them 45 days to render payment. After 60 days, you are responsible for the entire balance, paid-in-full.

We will gladly discuss your treatment with you and answer any questions relating to your insurance. You must realize, however, that:

1. Your insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract.

2. Not every service is a covered benefit with all insurance contracts. Some insurance companies are selective in what services they cover.

3. Services cannot be provided on the assumption that the charges will be paid by the insurance company; therefore, the patient is responsible for the bill, regardless of insurance coverage.

4. Some insurance companies, because we are not in network, will reimburse you directly. Because of this, we may require payment in full for all services.

Please note at your initial consultation appointment we collect the consult fee and any required x-rays/imaging in full. Financial arrangements for future treatment will be discussed at the time of your consultation. If your procedure is not covered by your plan, the balance is due in full prior to treatment.

Imaging policy: we offer a reduced imaging fee for patients proceeding with treatment at AOFS. If you elect to have treatment done elsewhere there is an additional fee for a copy of 3-D imaging.

If your insurance pays more than the balance due on your account, a refund will be issued to you promptly. Refunds are processed twice per month. Alaska Center for Oral + Facial Surgery is an accredited Ambulatory Surgery Center. There is potential billing charges associated with the use of this facility, this is dependent upon services that are rendered.

PATIENTS WITHOUT INSURANCE: Patients without insurance are required to pay all charges in full at the time of service. An estimate will be given to you at your examination/consultation appointment for proposed or planned treatment and a deposit may be collected at the time of scheduling your procedure.

PAYMENT OPTIONS: Personal check, cash, or Visa / Discover / Master Card/ AMEX may be used for payment on your account. There will be a $30.00 charge for all returned checks. Postdated checks will not be accepted.

HOSPITAL SURGERY: We recommend a pre-authorization for all hospital surgery. Financial arrangements for hospital surgeries are made on an individual basis when scheduling surgery.

ACCOUNT BALANCES: Payment is due 60 days after charges are incurred regardless of insurance payment. After this time finance charges will be applied to your account at 0.875% per month (10.5%) per year. Patients with insurance whose claims have not been paid within 45 days should contact their insurance company to determine the reason for delay of payment. Delinquent accounts will be referred for collection at the discretion of the business manager.

ASSIGNMENT AND RELEASE: For individuals with insurance, your signature below hereby authorizes your insurance benefits to be paid directly to Alaska Center for Oral + Facial Surgery. It also authorizes the doctor to release any information required for payment and processing of this claim. Please sign below to acknowledge your understanding and accept full financial responsibility of this account and information contained herein.

*Patient Name:

Guarantor Name (if different from Patient):

*Patient/Guarantor Signature:

*Date

Conclusion
Emergency Contact Details

First Name

Last Name

Home Phone

Mobile Phone

Relationship to Patient

HIPPA

We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 2/15/2016 and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law, and to make new Notice provisions effective for all protected health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new Notice upon request. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

HAVE RECEIVED AND REVIEWED A COPY OF OUR DENTAL PRACTICE’S PRIVACY, SECURITY AND BREACH NOTIFICATION POLICIES PROCEDURES.

I UNDERSTAND THAT I SHOULD ASK OUR DENTAL PRACTICE’S OFFICAL IF I HAVE ANY QUESTIONS ABOUT THESE POLICIES AND PROCEDURES.

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.

*Print Name

*Sign

*Date

I CONSENT TO YOUR DISCLOSURE OF MY INFORMATION, WHICH YOU DEEM ARE NECESSARY IN CONNECTION WITH MY TREATMENT. I UNDERSTAND THAT SUCH DISCLOSURES MAY NOT BE OF THE TYPE LISTED ABOVE.

*Patient Name

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

I authorize Alaska Center for Oral + Facial Surgery to release my health information to:

Clinic/Provider Name

Family/Representative:

Name:

Relationship:

Name:

Relationship:

Information to release (check one):

All medical & billing records
Limited to:
Insurance / Billing
Other:

Expiration:

1 year from today
Until revoked in writing

Date:

Acknowledgment: I understand I may refuse or revoke this authorization in writing at any time. Treatment/payment is not conditioned on signing. Information disclosed may no longer be protected by federal privacy law (HIPAA). This authorization complies with Alaska law. A copy is valid as the original.

*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.