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Who will be responsible for your account?

Father Mother Self Spouse Other

Who will be responsible for your account

Name / Social Security Number

Birth Date / Age

Responsible Party Phone

Email / Drivers License

Address

Employer / Business Name

Spouse or other guarantor information (if different from above)

Name / Relation to Patient

Birth Date / Social Security Number

Address

Employer / Business Name

Are you a student?

Full-time Part-time Not a student

School Information

School Name

School Address

Primary Dental Insurance Information

Employer

Business Address

City / State / Zip

Phone Number

Plan Name

Insurance Co. Name

Insurance Co. Address

City / State / Zip

Phone Number

Group

Insured Party Name

Relation / Birth Date

Insured Party Sex

Male Female

Insured Party Address

City / State / Zip

Phone / Soc. Sec. #

Policy I.D. Number

Primary Medical Insurance Information

Employer

Business Address

City / State / Zip

Phone Number

Plan Name

Insurance Co. Name

Insurance Co. Address

City / State / Zip

Phone Number

Group

Insured Party Name

Relation / Birth Date

Insured Party Sex

Male Female

Insured Party Address

City / State / Zip

Phone / Soc. Sec. #

Policy I.D. Number

Do you have secondary dental or medical insurance?

Yes No

Secondary Dental Insurance Information

Employer

Business Address

City / State / Zip

Phone Number

Plan Name

Insurance Co. Name

Insurance Co. Address

City / State / Zip

Phone Number

Group

Insured Party Name

Relation / Birth Date

Insured Party Sex

Male Female

Insured Party Address

City / State / Zip

Phone / Soc. Sec. #

Policy I.D. Number

Secondary Medical Insurance Information

Employer

Business Address

City / State / Zip

Phone Number

Plan Name

Insurance Co. Name

Insurance Co. Address

City / State / Zip

Phone Number

Group

Insured Party Name

Relation / Birth Date

Insured Party Sex

Male Female

Insured Party Address

City / State / Zip

Phone / Soc. Sec. #

Policy I.D. Number

Medications

Are you taking any prescribed or over the counter medications? If so, please list the name and dosage of the medication

Yes No

Have you ever taken cortisone / prednisone or other steroid drugs longer than 2 weeks?

Yes No

Are you taking or have you ever taken Bisphosphonates for osteoporosis or chemotherapy for multiple myeloma or other cancers, (Reclast, Fosamax, Actonel, Boniva, Areida or Zometa)?

Yes No

Women

Are you pregnant or could you be pregnant?

Yes No

Last period date

Are you nursing?

Yes No

I hereby certify that the answers I have given to the above questions are true and correct to the best of my knowledge. I will not hold my surgeon or any staff responsible for any errors or omissions that I may have made in the completion of this form.

Signature

Click to Sign

Date:-------------

Patient Financial Policy

Dr. Zysset and Dr. Tylka provide the finest oral surgery care at the most reasonable cost to our patients. It is our goal to treat each of our patients with the highest caliber of care and respect.

Payments
All estimated payments and balances are due at time of check-in. Self-pay patients will be required to pay in full the day service is rendered. For your convenience, we accept Visa, MasterCard, American Express, Discover, Care Credit, cash and personal checks. We do not accept installments. A finance charge of 1.333% per month (16% annual) will be added to all past due accounts with balances over 90 days.

Insurance Claims
We are in network with Ameritas, BCBS (both medical & dental), Cigna Dental, Delta Dental, Principal and The Standard. Oral surgery procedures may be covered by dental and/or medical insurances, depending on your coverage. Please note we do not offer free consultations in this office. As a service to our patients, we will bill your primary and secondary insurance carrier (that we are in network with), provided proper paperwork is provided to us. This does not imply that your particular plan will cover your anticipated procedure, either in part or in full. Insurance is a contract between you and your insurance company. The ultimate responsibility for any unpaid balance rests with the guarantor/patient. Although we may provide an estimate of what your insurance may pay, we cannot be responsible for any discrepancy between what the insurance company quotes to us and what they actually pay. If the insurance company pays the policy holder directly, the policy holder must contact our office and is responsible for payment and agree to forward payment to us immediately.

Sedation
Some insurance companies will not pay for a patient to use sedation. If sedation is NOT allowed by your insurance company, you will be responsible for paying for the use of sedation in full.

Returned checks
The charge for a returned check is $35 payable by cash or credit card.

Outstanding balance policy
It is our policy that all past due accounts receive three statements. If payment is not made, we will make a final attempt to collect. If no resolution can be made, the account will be sent to a collection agency, along with possible discharge from the practice.

Assignment of insurance benefits
I hereby assign to Monte K. Zysset, DDS, FACS or Daniel J Tylka, DDS, MD the insurance benefits which are otherwise payable to me for their charges and direct that insurance payments be made directly to them. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as solid as an original. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the assignee to release all information necessary to secure the payment.

Guarantor/Patient's signature

Signature label

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Date:-------------

I, hereby acknowledge that I have reviewed a copy of this practice's Notice of Privacy Practices. I have been given the opportunity to ask any questions I may have regarding this Notice.

Name

Signature

Click to Sign

Date:-------------

Patient Disclosure Instructions

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.

I agree that the dental practice may communicate with me electronically via email. I am aware that there is some level of risk that third parties might be able to read unencrypted emails. I can withdraw my consent to electronic communications by calling: 402-423-7171.

I wish to be contacted in the following manner (check all that apply):

Home Number

Leave message with detailed info

Yes No

Leave message with call back number only

Yes No

I wish to be contacted in the following manner (check all that apply):

Cell Number

Leave message with detailed info

Yes No

Leave message with call back number only

Yes No

I wish to be contacted in the following manner (check all that apply):

Work Number

Leave message with detailed info

Yes No

Leave message with call back number only

Yes No

I wish to be contacted in the following manner (check all that apply):

Written Communication

Mail to my home address

Yes No

E-Mail

Yes No

Text to cell phone

Yes No

I authorize my surgeon /staff to perform an Oral and Maxillofacial examination for the purpose of diagnosis and treatment planning. I also authorize the taking of all x-rays/photos required as a necessary part of this examination. If continuation of care is medically needed by other professionals or insurance companies, I authorize the release of any information acquired through the course of examination and treatment.

Patient Signature

Click to Sign

Date:-------------

Print Name

truForm by PBHS

Main Header

Demographic Information

Patient information

Who will be responsible for your account

Spouse or other guarantor information (if different from above)

Insurance Information

General Insurance Information

School Information

Primary Dental Insurance Information

Primary Medical Insurance Information

Secondary Dental Insurance Information

Secondary Medical Insurance Information

Health History

Since your well-being is our primary concern, please take time to accurately answer the following questions.

Have you had or do you currently have any of the following? (check Yes or No for each one)

Allergies / Medications

Are you allergic to: (please check)

Medications

Women

Click to Sign

Financial Policy

Patient Financial Policy

Click to Sign

Notice of Privacy Practices

Click to Sign

Patient Disclosure Instructions

I wish to be contacted in the following manner (check all that apply):

I wish to be contacted in the following manner (check all that apply):

I wish to be contacted in the following manner (check all that apply):

I wish to be contacted in the following manner (check all that apply):

I allow you to give my clinical information to or answer questions from (check all that apply):

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Main Header

Demographic Information

Patient information

Who will be responsible for your account

Spouse or other guarantor information (if different from above)

Insurance Information

General Insurance Information

School Information

Primary Dental Insurance Information

Primary Medical Insurance Information

Secondary Dental Insurance Information

Secondary Medical Insurance Information

Health History

Since your well-being is our primary concern, please take time to accurately answer the following questions.

Have you had or do you currently have any of the following? (check Yes or No for each one)

Allergies / Medications

Are you allergic to: (please check)

Medications

Women

Click to Sign

Financial Policy

Patient Financial Policy

Click to Sign

Notice of Privacy Practices

Click to Sign

Patient Disclosure Instructions

I wish to be contacted in the following manner (check all that apply):

I wish to be contacted in the following manner (check all that apply):

I wish to be contacted in the following manner (check all that apply):

I wish to be contacted in the following manner (check all that apply):

I allow you to give my clinical information to or answer questions from (check all that apply):

Click to Sign

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

This form requires that you disable private browsing to continue. Please open a new browser window and reload the form.

This form requires that you disable private browsing to continue.
Please open a new browser window and reload the form.