PerioNW - Patient Form

General Insurance information

Employed

Marital status

Are you a student?

School Name

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

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 or medical insurance?

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

Cancer

Diabetes

Heart Disease

Anesthesia Problems

Autism

*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

*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

Difficult breathing/other lung trouble

*Fainting spells

*Convulsions/ epilepsy

*Stroke

*Thyroid trouble

*Diabetes

*Low blood sugar

*Kidney trouble

*High cholesterol

*Are you on dialysis?

*Osteoporosis/ osteopenia

*Osteonecrosis

*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

Swollen ankles, arthritis, or joint disease

Stomach Ulcers / Acid Reflux

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.

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

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?

First Name

Last Name

Home Phone

Mobile Phone

Relationship to Patient

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

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.

We honor most insurance plans and will be happy to process your claims for you. We will do our best to estimate how much your insurance will contribute towards your treatment as well as give you estimates of what portions will be due from you at the time of service. It is important that you provide us with complete and accurate insurance information so that your claims can be processed properly. If at any time your insurance coverage changes, please take a moment to notify our office right away. 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 insurance, we will be glad to fill out the proper forms, but please complete the identifying information on this form. Any future major treatment will require a non-refundable deposit at the time of appointment reservation. Remaining estimated patient portion is due at time of service 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. We will do everything we can to obtain the maximum benefits available to you through your insurance coverage but we do need to advise you that ultimately you are responsible for all charges incurred on your behalf regardless of insurance coverage. 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. Payment Options Cash, Checks, Debit Cards, Visa, MasterCard, American Express, Discover and CareCredit For those patient without insurance we extend a 5% discount For extensive treatment plans, we can provide you with outside financing through CareCredit or pre-payments in our office. Please inquire if you are interested. CANCELLATION POLICY We understand that emergencies do occur. If you are unable to make your appointment, please notify our office 48 hours prior to your scheduled time for cleanings and exams and 5 business days prior to your scheduled time for surgery. If you fail to make your scheduled time and do not notify us accordingly, you may be charged a broken appointment fee of $50 for exams and cleanings and $100 for surgical appointments. If you miss more than two (2) scheduled appointments, we may request that you seek care at another dental office that can better accommodate your schedule. These fees are not meant to cover our loss, but to enhance commitment to treatment and communication with our office. We wholeheartedly believe in maintaining excellent oral health and keeping appointments are necessary to meet our goals. Repeated late cancellations or no shows are disruptive to the optimal delivery of care and may indicate a lack of commitment to your health and wellness. As a result, 2 cancellations or no shows will result in discontinuing prescheduled appointments. Patients will be placed on a “quick call only” list and can be scheduled as time permits. Thank you Thank you for choosing PerioNW for your dental care. Dental treatment is an excellent investment in an individual’s physical and mental well-being. We are always available to answer your questions or assist you in any way we can. We appreciate your continued support. Reading and signing this policy states you understand the policy. All late cancels and no shows not excluded from this policy will be billed to you, holding you responsible for paying the fees. Thank you once again in helping us on our constant path towards excellence.

*I HAVE READ AND UNDERSTAND THE ABOVE POLICY: 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.

I authorize my surgeon and her designated staff, to perform an oral and maxillofacial 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 any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers. 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.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected Health Information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. USES AND DISCLOSURE OF PROTECTED HEALTH INFORMATION: Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law. TREATMENT: We will use and disclose your PHI to provide, coordinate or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your PHI, as necessary, to a home health agency that provides care to you. Or, your PHI may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. PAYMENT: Your PHI will be used, as needed, to obtain payment for your health care services. For example obtaining approval for a hospital stay may require that your relevant PHI be disclosed to the health plan to obtain approval for the hospital admission. HEALTHCARE OPERATIONS: We may use or disclose, as needed, your PHI in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your PHI, as necessary, to contact you to remind your of your appointment. AUTHORIZATION: We may use or disclose your PHI in some situations without your authorization. These situations include: As Required By Law, Public Health issues as required by law, Communicable Diseases, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, Organ Donation, Research, Criminal Activity, Military Activity, National Security, Workers’ Compensation, Inmates Required Uses and Disclosures. Under the law we must make disclosure to you and when required by the Secretary of the Dept. of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500. OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES will be made only with your consent, authorization or opportunity to object unless required by law. YOU MAY REVOKE THIS AUTHORIZATION at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization. THE FOLLOWING IS A STATEMENT OF YOUR RIGHTS WITH RESPECT TO YOUR PROTECTED HEALTH INFORMATION. YOU HAVE THE RIGHT TO INSPECT AND COPY YOUR PROTECTED HEALTH INFORMATION. Under Federal Law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding and protected health information that is subject to law that prohibits access to protected health information. YOU HAVE THE RIGHT TO REQUEST A RESTRICTION OF YOUR PROTECTED HELTH INFORMATION. This means you may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment or healthcare operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in the Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your PHI, your PHI will not be restricted. You then have the right to use another Healthcare Professional. YOU HAVE THE RIGHT TO REQUEST TO RECEIVE CONFIDENTIAL COMMUNICATIONS FROM US BY ALTERNATIVE MEANS OR AT AN ALTERNATIVE LOCATION. YOU HAVE THE RIGHT TO OBTAIN A PAPER COPY OF THIS NOTICE FROM US upon request, even if you have agreed to accept this notice alternatively (i.e. electronically). YOU MAY HAVE THE RIGHT TO HAVE YOUR PHYSICIAN AMEND YOUR PROTECTED HEALTH INFORMATION. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. YOU HAVE THE RIGHT TO RECEIVE AN ACCOUNTING OF CERTAIN DISCLOSURES WE HAVE MADE, IF ANY, OF YOUR PROTECTED HEALTH INFORMATION. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. COMPLAINTS: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. This notice was published and becomes effective on/or before APRIL 14, 2003. We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected heath information. If you have any objections to the form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number, 360-757-7667. ---

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

*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.