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Oral and Maxillofacial Surgery of Elkhart, Daniel Burns DDS, MD - 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

DENTIST NAME

First Name

Last Name

Practice Name

ORTHODONTIST NAME

First Name

Last Name

MEDICAL DOCTOR NAME

First Name

Last Name

PREFERRED PHARMACY

Preferred Pharmacy Name

Preferred Pharmacy Phone

EMERGENCY CONTACT DETAILS

*First Name

*Last Name

*Primary Phone

Secondary Phone

*Relationship to Patient

*I hereby designate the following individual(s) as my emergency contact(s). In the event of a medical emergency or if I am incapacitated, I authorize healthcare staff to share my protected health information (PHI) with these individuals as necessary for my care

GUARANTOR INFORMATION

*Who will be responsible for your account?

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

Are you a student?

Employer Name

Employer Phone Number

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

Insured 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

Insured Party Address 2

City

State

Zip

PRIMARY DENTAL INSURANCE INFORMATION

Employer / Business

Business Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Insurance Phone Number

Group Name

Group Number

Upload your insurance card

Maximum allowed size : 25MB

Upload the back your insurance card

Maximum allowed size : 25MB
PRIMARY MEDICAL INSURANCE INFORMATION

Employer / Business

Buisiness Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Insurance Phone Number

Group Name

Group Number

Upload your insurance card

Maximum allowed size: 25MB

Upload the back of your insurance card

Maximum allowed size: 25MB

Do you have secondary dental or medical insurance?

ACCIDENT

Is this related to an accident?

If Yes, What type?

Date of Injury

Insurance Company Handling This Claim

Insurance Claim Number

Name of Attorney / Adjustor

Attorney / Adjustor Phone

If work-related, name of human resources contact

if work-related phone number of human resources contact

VERIFICATION

I certify that I have read and I understand the questions herein. I acknowledge that my questions, if any, about the inquiries set forth herein 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.

NOTICE OF PRIVACY PRACTICES

The Notice of Privacy Practices describes how my health information may be used or disclosed. I understand that I should read it carefully. I am aware that the notice may be changed at any time, and I have the right to request new copies of this Notice at our office during regular business hours. I have been given an opportunity to review the Notice of Privacy Practices.

*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.

CONSENT TO TREATMENT

I consent to the administration of health care by Oral and Maxillofacial Surgery of Elkhart, also known as OMSE, the office of Daniel A. Burns, D.D.S., M.D., which includes the administration of health care by assistants and medical personnel as selected and supervised by OMSE and Daniel A. Burns, DDS, MD. I understand that I may set conditions or limitations on my treatment and care and that if I wish to provide such conditions, I will be given an opportunity to express those conditions or limitations in a separate document. I have been informed and acknowledge that I may withdraw my Consent to Treatment at any time upon written notice to this office. I hereby knowingly and voluntarily enter into this Consent to Treatment. By my signature below, I am acknowledging receipt of a copy of this document and agree to the terms under all sections of this document: Consent to Treatment, Agreement to Pay and Assign Benefits, and Acknowledgement of receipt of HIPAA Privacy Practices.

*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.

DISCLOSURE OF MEDICAL INFORMATION

I give express permission for the following individual(s) to have access to my medical information. If permitting multiple persons to access your information, please list all names below, separated by a comma.

First and Last Name

*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.

DISCLOSURE OF FINANCIAL INFORMATION

I give express permission for the following individual(s) to have access to my financial information. If permitting multiple persons to access your information, please list all names below, separated by a comma.

First and Last Name

*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.

CONSENT TO RECEIVE TEXT MESSAGES

OMSE and the office of Daniel A. Burns, D.D.S., M.D. may text me regarding my care, including but not limited to, appointment reminders and billing updates. I may opt-out by contacting the office to request this. I give this office my approval to text my provided cell phone number

*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 with any involved insurance company

*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.

AGREEMENT TO PAY AND BENEFIT ASSIGNMENT

I agree to pay for all services and charges rendered to me by OMSE and/or Daniel A. Burns, D.D.S., M.D., P.C. I agree that I am responsible to provide timely information about my insurance coverage, any changes in coverage, and respond promptly to requests for information as they occur. I assign to OMSE and/or Daniel A. Burns, D.D.S., M.D., P.C. benefits due to me or become due to me as a result of the medical or dental services I receive from OMSE and/or Daniel A. Burns, D.D.S., M.D. or other qualified healthcare provider to pursue any health insurer, third party administrator, health plan (insured or self-funded) for payment provided directly or indirectly by OMSE and/or Daniel A. Burns, D.D.S., M.D. This includes any right to appeal any part of any claim denied or partially paid and to file any administrative or legal proceeding to pursue payment. I further assign OMSE and/or Daniel A. Burns, D.D.S., M.D., P.C. all rights to obtain plan documents, summary plan descriptions, and health insurance related policy documents. I further authorize the payments to be paid directly to OMSE and/or Daniel A. Burns, D.D.S., M.D. I understand that I am responsible to OMSE and/or Daniel A. Burns, D.D.S., M.D. or any payments made directly to me for services OMSE and/or Daniel A. Burns, D.D.S., M.D. provided to me. If this account is not paid in accordance with OMSE and Daniel A. Burns, D.D.S., M.D., P.C.’s policies, I agree and guarantee to pay collection costs, including reasonable attorney fees, collection agency fees and interest from the date of demand

a. Financial Responsibility: Additionally, I agree to pay all charges and account balances that are not paid in full by the assigned insurance company or third-party payer. I understand that payment is immediately due when services are rendered. If amounts due to the healthcare providers are not paid after reasonable notice and healthcare providers’ efforts to collect, then the account will be considered delinquent and additional service charges may be added to the account balance to offset additional incurred collection expenses. In the event that I avoid or refuse to pau or that I default on agreed payment arrangements and terms, I understand that I will be responsible for any and all reasonable attorney and legal fees, court costs, and incurred collection costs and expenses. If the debt is assigned to a third-party collection service, then I agree to be responsible for the collection fees and interest as allowed by Indiana statute on the outstanding debt. I understand that debts referred to a third party for collection will be reported to credit reporting entities and will be reflected in my personal credit file history. If a check payment is returned for any reason, a $15 NSF charge will be applied to the patient’s account. If you present two checks that are returned to us, we will require cash or card payments for any future services.

b. Minor patients: A parent or legal guardian must accompany patients 17 years old and younger, and sign as responsible party below, with the exception of patients 17 years and younger who are declared emancipated minors. It is the parent or guardian’s responsibility to bring the necessary referrals, insurance card(s), and to make payment at the time of services. OMSE and/or Daniel A. Burns, D.D.S., M.D. will recommend medically appropriate treatment for the patient. In the event your health plan deems a service medically unnecessary, experimental, non-covered, and/or inclusive, as responsible party you agree to pay for any amounts not covered by the carrier. I acknowledge my understanding and agree that I am legally responsible for my account and all costs associated with the collection of my account. Account balances after insurance must be paid in full within 30 days of patient billing, unless other payment arrangements have been made to avoid collection agency action

*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.