Main Header

6904 Colleyville Blvd • Colleyville • TX • 76034
P: 817.552.3223 • F: 817.552.3224
www.TXOSS.com

WELCOME

Thank you for selecting TXOSS for your oral & maxillofacial team! We will strive to provide you with the best possible oral surgery care. To help us meet all your oral surgery healthcare needs, please ﬁll out and Submit this form. After Submitting Online, please print and bring a copy with you.

GUARANTOR

(Financial responsibility and appointment scheduling)

Self Spouse Parent Other

Legal Name

Sex / Relationship

Male Female

Birthdate / Soc. Sec. #

Address

City / State / Zip

Employer / Work Phone

Cell / Home Phone

EMERGENCY CONTACT INFORMATION

Name

Relationship / Cell

Home Phone / Work Phone

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION TO

Texas Oral Surgery Specialist may hereby release PHI to the following via Phone call, Voice Message, e-Mail or written correspondence. Texas Oral Surgery may also release PHI to immediate family members of the Patient via Phone call, Voice Message, e-Mail or written correspondence.

Name

Relationship / Cell

Name

Relationship / Cell

Name

Relationship / Cell

PRIMARY DENTAL INSURANCE

Insurance Company

Group Name/#

Insured DOB

Ins. Co. 800 #

Name of Policyholder

Relationship to Patient

Self Parent Spouse Other

Policyholder’s Birthdate

Soc. Sec. # / Member ID

Employer

PRIMARY MEDICAL INSURANCE

Insurance Company

Group Name/#

Insured DOB

Ins. Co. 800 #

Name of Policyholder

Relationship to Patient

Self Parent Spouse Other

Policyholder’s Birthdate

Soc. Sec. # / Member ID

Employer

SECONDARY DENTAL INSURANCE

Insurance Company

Group Name/#

Insured DOB

Ins. Co. 800 #

Name of Policyholder

Relationship to Patient

Self Parent Spouse Other

Policyholder’s Birthdate

Soc. Sec. # / Member ID

Employer

SECONDARY MEDICAL INSURANCE

Insurance Company

Group Name/#

Insured DOB

Ins. Co. 800 #

Name of Policyholder

Relationship to Patient

Self Parent Spouse Other

Policyholder’s Birthdate

Soc. Sec. # / Member ID

Employer

Accident or Injury

Is this visit related to an accident?

Yes No

Nature of Accident

Automobile accident

Work Related accident

other

Date of Injury

Insurance company handling this claim

Ins. Phone No. / Claim Number

AUTHORIZATION

I authorize Texas Oral Surgery Specialists to release any information, including the diagnosis and records of any treatment or examination rendered to me or my child, to third party payers and/or other health practitioners, to the extent permitted by law.

I understand my Medical and/or Dental insurance carrier may pay less than the actual bill for services or the estimated insurance payment. I agree to be responsible for payment of all services rendered on my or my dependent’s behalf within 60 days of treatment, regardless if insurance payment has been received.

I understand that Dr. Chris Tye, MD, DDS nor Associates are contracted with Medical Insurance Plans (HMO/PPO/etc.). I understand I may seek treatment with an in network Medical provider. I hereby waive my Consumer Protection Rights for Balance Billing under Texas Senate Bill 1264, and I hereby Agree to pay Full Billed Fees of Texas Oral Surgery Specialists and/ or Dr. Chris Tye, MD, DDS or Associates for any Medical services rendered, and NOT the Medical Insurance Contracted Fees. I have a legal right to cancel this waiver of Consumer Protection Rights for Balance Billing within 5 days of signing below.

Signature of Patient (parent or guardian, if minor)

Click to Sign

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

Signature of responsible party

Click to Sign

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

*Please remember to bring insurance cards and driver’s license to your Consultation Appointment.

Health Care Doctors

Please Provide the Following Information on your Health Care Doctors: (Primary Care, Cardiologist if applicable, Dentist, Orthodontist if applicable)

Primary Care

TEL / Last VIsit Mo/Yr

Cardiologist

TEL / Last VIsit Mo/Yr

Dentist

TEL / Last VIsit Mo/Yr

Orthodontist

TEL / Last VIsit Mo/Yr

Other Physicians

Are you under the care of other Physicians / Dental Specialists? If so describe below

Yes No

SPECIALTY

NAME

TEL / CONDITION

SPECIALTY

NAME

TEL / CONDITION

SPECIALTY

NAME

TEL / CONDITION

SPECIALTY

NAME

TEL / CONDITION

SPECIALTY

NAME

TEL / CONDITION

SPECIALTY

NAME

TEL / CONDITION

SPECIALTY

NAME

TEL / CONDITION

SPECIALTY

NAME

TEL / CONDITION

Have you had any major illness(es), operation(s) or been previously been hospitalized in the past 5 years?

Yes No

If so, describe

Describe / Date

Pharmacy

Pharmacy Name

City / Zip / Phone

Please list ALL medications you are currently taking - including over the counter.

None

Yes No

Please list ALL allergies to medication(s) or materials (latex, tape, eggs, etc.) you are allergic to and include the reaction (rash, nausea, anaphylaxis, shock, other)

None

Yes No

AUTHORIZATION

I certify that I have read and understand the questions above and have answered the questions truthfully. I acknowledge that my questions, if any, have been answered to my satisfaction. I will not hold TXOSS, my surgeon or any member of the staﬀ responsible for any errors or omissions that I have made in the completion of this form. I will report any changes in my medical/dental health to the office during my care at TXOSS. I authorize my surgeon and his staﬀ to complete an oral and maxillofacial examination for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all radiographic imaging and/or impressions as required for my treatment.

Signature of Patient (parent or guardian, if minor)

Click to Sign

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

CONSENT FOR DISCLOSURE OF HEALTH CARE INFORMATION: PURPOSES OF TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS

Doctor’s Name: Dr. Chris Tye, MD, DDS & Associates

Practice Name: Texas Oral Surgery Specialists (a.ka. TXOSS)

General Consent: I hereby consent to Texas Oral Surgery Specialists (hereafter referred to as doctor, or facility) to provide me with necessary medical and/or dental services, treatment(s) and diagnostic test(s). My consent to this treatment includes any examinations, X-rays, laboratory procedures, medications, medical and/or dental treatment or procedures, and/or other services rendered by the Doctor(s) or other treating or consulting Doctor(s), their associates, technical assistants and other healthcare providers, which in the judgment of such practitioners, are advisable during the course of evaluation, diagnosis and treatment. This consent is continuing in nature during the entire course of my care, unless specifically revoked by me.

Control Over Decisions: I have the right to make decisions about my care. My healthcare professionals and I will discuss and agree upon my care, unless such care is considered urgent or emergent in nature.

Testing After Accidental Exposure: I understand that Texas law provides, if any healthcare worker is exposed to the patient’s blood or other bodily fluid, that Doctor may perform test(s) on the patient’s blood or other bodily fluid to determine the presence of any communicable disease. I consent to the testing for other communicable diseases, in the event of an accidental exposure to a healthcare worker. I understand that such testing is necessary to protect those who will be caring for the patient.

Personal Property: I understand that I am responsible for my personal property. I understand that any and all valuables or other articles of personal property should be placed in the care of a family member or other authorized representatives. The facility is not responsible for safekeeping these items.

Financial Responsibility: It is agreed and understood that regardless of any and all assigned benefits/monies, I, as the designated responsible party, am responsible for the total charges for services rendered, regardless of insurance, and I further agree that all amounts for service are due upon request and are payable to Texas Oral Surgery Specialists, PA and any practitioner providing me care and agree to pay for any and all charges and expenses incurred or to be incurred. I understand that the practitioners providing me care may be out-of-network on my health or dental or insurance plans. I understand my insurance may not cover some services provided to me. I am responsible for asking about and understanding my insurance coverage and selecting my healthcare providers and facilities. Only my insurance carriers can confirm the nature and extent of my coverage and which providers or procedures will be paid in-network. I agree to be responsible for payment of all services rendered on my or my dependent’s behalf within 60 days of treatment, regardless if insurance payment has been received. It is further agreed and understood that should this account become delinquent and it becomes necessary for the account to be referred to any attorney or collection agency for collection or suit, I, as the designated responsible party, shall pay all charges for reasonable attorneys’ fees and collection expenses. I agree that if this account results in a credit balance, the credit amount will be applied to any outstanding accounts, either current or bad debt.

Payments: Payment is due at the time services are rendered.

Medicare and Medicaid: Neither Texas Oral Surgery Specialists, PA, nor Dr. Chris Tye nor Associates are participating Providers of Medicare or Medicaid. If I have Medicare or Medicaid, my financial obligations may be limited by law. Other insurance carriers may limit my obligations by contract or policy benefit guidelines.

Assignment of Benefits: I assign, transfer and convey to Texas Oral Surgery Specialists, PA and any practitioner providing care and treatment to me, any and all benefits, interests and rights (including, but not limited to, the right to enforce payment and the right to appeal an adverse benefit determination) to which I am entitled under an employee welfare benefit plan sponsored by my employer, all insurance policies, benefits, any third party reimbursement, or prepaid health care plan for services rendered or products that I receive from Texas Oral Surgery Specialists, PA.

Release of Information: I understand that the facility may release my healthcare information for payment purposes and any other purpose permitted by law. Further, the facility may release my information to other providers for my continued care.

Communication: I authorize Texas Oral Surgery Specialists, along with any billing service and their collection agency or attorney who may work on their behalf, to communicate with me, my immediate family members, and/or my emergency contact on my cell phone and/or home phone and/or other phone listed on my patient registration using pre-recorded messages, digital voice messages, automatic telephone dialing devices or other computer assisted technology, or by electronic mail, text messaging or by any other form of electronic communication. Communication may include, but is not limited to, my care, billing, appointments, surveys and/or social media.
- I understand that I have the right to request in writing a restriction on uses and disclosures of my protected health information (PHI). I have the right to request in writing that communication is kept confidential or that a communication of PHI be made by alternative means.

Retention of Records: I understand that the facility will retain my medical and/or dental records for the required retention period. I acknowledge that the facility may authorize the disposal of patient medical and/or dental records at the end of this retention period.

Notice of Privacy Practices: I acknowledge that I have received, and read and understand, the facility’s ‘Notice of Privacy Practices’ which is available in the office(s), on the website www.TXOSS.com, or by request. I consent to the use or disclosure of my protected health information as described in the Notice of Privacy Practices by Texas Oral Surgery Specialists, it’s employees and staff, for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills, communication with other health care workers, or to conduct the health care operations of Texas Oral Surgery Specialists.

Warranty and Guarantee: I am aware that the practice of medicine and/or dentistry is not an exact science and acknowledge that no warranties or guarantees have been made about the results of my care and treatment rendered by Texas Oral Surgery Specialists, PA or the Doctor(s).

I hereby acknowledge that a copy of this office’s: 1) “Notice of Privacy Practices” 2) “Financial Policy” and 3) “Patient’s Rights Policy” have been made available to me on the website www.TXOSS.com, posted in the office(s), or obtained from the office via written request. I acknowledge that I have had an opportunity to read, understand and agree to TXOSS, P. A.’s: 1) “Notice of Privacy Practices” 2) “Financial Policy” and 3) “Patient’s Rights Policy”.

Signature of Patient (parent or guardian, if minor)

Click to Sign

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

Relationship to Patient

Self Parent Legal Guardian Other

6904 Colleyville Blvd | P: 817.552.3223 F: 817.552.3224 | www.TXOSS.com

truForm by PBHS

Main Header

WELCOME

Patient Information

PATIENT INFORMATION (confidential)

GUARANTOR

EMERGENCY CONTACT INFORMATION

Authorization to Release Protected Health Information

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION TO

Insurance Information

PRIMARY DENTAL INSURANCE

PRIMARY MEDICAL INSURANCE

SECONDARY DENTAL INSURANCE

SECONDARY MEDICAL INSURANCE

Accident or Injury

AUTHORIZATION

Click to Sign

Click to Sign

Medical Health History

Medical Health History

Health Care Doctors

Other Physicians

Have you had any major illness(es), operation(s) or been previously been hospitalized in the past 5 years?

Pharmacy

Medications / Allergies

MEDICATIONS - Are you taking..

Please list ALL medications you are currently taking - including over the counter.

ALLERGIES AND REACTIONS - Are you allergic to, or had a reaction to...

Please list ALL allergies to medication(s) or materials (latex, tape, eggs, etc.) you are allergic to and include the reaction (rash, nausea, anaphylaxis, shock, other)

Medical Health History Continued

AUTHORIZATION

Click to Sign

Consent for Disclosure of Health Care Information

CONSENT FOR DISCLOSURE OF HEALTH CARE INFORMATION: PURPOSES OF TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS

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.

Main Header

WELCOME

Patient Information

PATIENT INFORMATION (confidential)

GUARANTOR

EMERGENCY CONTACT INFORMATION

Authorization to Release Protected Health Information

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION TO

Insurance Information

PRIMARY DENTAL INSURANCE

PRIMARY MEDICAL INSURANCE

SECONDARY DENTAL INSURANCE

SECONDARY MEDICAL INSURANCE

Accident or Injury

AUTHORIZATION

Click to Sign

Click to Sign

Medical Health History

Medical Health History

Health Care Doctors

Other Physicians

Have you had any major illness(es), operation(s) or been previously been hospitalized in the past 5 years?

Pharmacy

Medications / Allergies

MEDICATIONS - Are you taking..

Please list ALL medications you are currently taking - including over the counter.

ALLERGIES AND REACTIONS - Are you allergic to, or had a reaction to...

Please list ALL allergies to medication(s) or materials (latex, tape, eggs, etc.) you are allergic to and include the reaction (rash, nausea, anaphylaxis, shock, other)

Medical Health History Continued

AUTHORIZATION

Click to Sign

Consent for Disclosure of Health Care Information

CONSENT FOR DISCLOSURE OF HEALTH CARE INFORMATION: PURPOSES OF TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS

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.