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Welcome to Blum-Nico Oral Surgery Associates
www.BlumNico.com

Miami Beach
4308 Alton Rd. #850, Miami Beach, Fl 33140
T: (305) 538-4556

Aventura
2999 N.E. 191 St. #607, Aventura, Fl 33180
T: (305) 936-5974

Medical Insurance Coverage Information:

Insured’s Name

Date of Birth

Social Sec. No.

Name of Insurance Co.

Plan/ID No.

Dental Insurance Coverage

Insured’s Name

Date of Birth

Social Sec. No.

Name of Insurance Co.

Plan/ID No.

Method of Payment:

Insurance Credit Card Cash/Check Other

I understand the importance of providing a truthful health history to assist my doctor in providing the best care possible. I have had the opportunity to discuss my health history with my doctor and the information I have provided here is complete and accurate.

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This Section Is For Women Only

A. If you are using oral contraceptives it is important that you understand that antibiotics and other medications may interfere with the effectiveness of oral contraceptives. Therefore, you will need to use mechanical forms of birth control for one complete cycle of birth control pills after the course of antibiotics or other medications s completed. Please consult with your physician for further guidance.

B. If you are pregnant, possibly pregnant, or trying to become pregnant, surgery, anesthetics or any other medication may significantly harm your developing baby, especially during the first trimester. Please advise your doctor if there is any chance of your being pregnant.

Are you pregnant or planning pregnancy?

Yes No

Are you taking birth control pills?

Yes No

Are you taking hormone replacements?

Yes No

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CONSENT , FEES AND PAYMENTS

CONSENT AND RELEASE OF RECORDS

The information, both on this page and on the medical history, are correct to the best of my knowledge. I authorize the doctors from Blum-Nico Oral Facial Surgery Associates and their designated staff, to perform an oral and maxillofacial examination and take x-rays as required for the purpose of diagnosis and treatment planning. Furthermore, I authorize the release of any records from my medical doctor, dentist, or specialist needed for diagnosis and treatment. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment.

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CONSENT TO USE RECORDS

I hereby give permission for the use records including photographs taken during the examination(s), treatment, and retention for the purposes of professional consultations, research, education, or publication in professional journals. I consent to the taking of photograph(s) and video(s) of the undersigned which may be reproduced and/or used in any and all advertisement or promotional purposes for the above doctor(s) and practice, including but not limited to websites, Facebook, Twitter, and other social media. In giving this consent, I release the above practice and doctor(s) from liability for any violation of any personal or proprietary right I may have in connection with such photograph/video reproduction or use.

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FEES AND PAYMENTS

Thank you for choosing our office for your oral surgery care. Any fees or payments are due the date of service. Payment arrangements can be made depending on special circumstances at the discretion of our office. An estimate of the charge for any surgical procedure can be given upon request. A finance charge (18% annually) will be added to any balance over 30 days. I further agree that I will be responsible for all collections costs, attorney’s fees and court costs. Please remember that insurance is considered a method of reimbursing the patient for fees paid to doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures while others pay a percentage of the charge. If you have any dental and/or medical insurance we will be glad to fill out the proper forms you. Please complete the identifying information on this form. The signature below on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to the doctornamed in the benefits, or otherwise payable to me.

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Financial Policy

Thank you for choosing Blum-Nico Oral-Facial Surgery Associates for your oral surgery needs. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of our mission is making the cost of optimal care as easy and manageable as possible for our patients by offering several payment options.

Payment Options
For your convenience, our office accepts several methods of payment. These include:
- Cash, Check, Wire Transfer, Visa, Mastercard, Discover, or American Express
- Third party financing from CareCredit and Lending Club are available (where our office pays the interestfor you for select plans).*2

These plans:
• Allow you to pay over time, some plans with NO INTEREST *1
• Offer convenient, low monthly payment plans
• Have no annual fees or pre-payment penalties

Scheduling/Cancellations/Late Patients
Our office requires full payment prior to the beginning of your treatment. A 50% deposit is required to secure your initial treatment appointment and the balance is due three days before the day of surgery or one week before if paying by check. If you choose to discontinue care before treatment is complete, you will receive a refund less incurred costs plus the cost of care received. A 48 hour notice is required for schedule changes or to receive a refund of your deposit. If you choose to cancel your surgery with less than a 48-hour notice, then you will be assessed a cancellation fee of $800 or your deposit amount (whichever is the lesser amount).

Our office has reserved specific surgery appointment times for you. As a courtesy we ask that you come to your surgery appointment on time. If you are going to be tardy, please call our office. If you are more than 15 minutes late, we will have to reschedule your appointment.

Refunds on Credit Card Payments
If you choose to pay with a credit card and later receive a refund, please note that the refund amount will be processed minus a 3% credit card processing fee. This fee reflects the costs incurred by our practice for processing your credit card payments.

Dental insurance
Our office does not participate with any insurance company. However, for patients with dental insurance we are happy to file the necessary paperwork to your carrier to help you maximize your benefits and provide you with the documentation you need to receive reimbursement for your treatment. The patient is ultimately responsible for fees due to the practice regardless of insurance payment.

If you have any questions, please do not hesitate to ask. We are here to help you get the treatment you want and need in the most comfortable way possible. I have read and understand the financial policy above.

*¹If paid within the promotional period. Otherwise, interest assessed from purchase date. Minimum monthly payment required.
*²Subject to credit approval

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Welcome to Blum-Nico Oral Surgery Associates
www.BlumNico.com

Demographic Information

Patient information

Insurance Coverage Information

Medical Insurance Coverage Information:

Dental Insurance Coverage

Health History

Health History

HAVE YOU HAD OR DO YOU CURRENTLY HAVE… PLEASE ANSWER ALL QUESTIONS BY CHECKING YES OR NO

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This Section Is For Women Only

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Conclusion

CONSENT , FEES AND PAYMENTS

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HIPAA PRIVACY FORM

Acknowledgement of Receipt of Notice of Privacy Practices

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Financial Policy

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Main Header

Welcome to Blum-Nico Oral Surgery Associateswww.BlumNico.com

Demographic Information

Patient information

Insurance Coverage Information

Medical Insurance Coverage Information:

Dental Insurance Coverage

Health History

Health History

HAVE YOU HAD OR DO YOU CURRENTLY HAVE… PLEASE ANSWER ALL QUESTIONS BY CHECKING YES OR NO

Click to Sign

This Section Is For Women Only

Click to Sign

Conclusion

CONSENT , FEES AND PAYMENTS

Click to Sign

Click to Sign

Click to Sign

Click to Sign

HIPAA PRIVACY FORM

Acknowledgement of Receipt of Notice of Privacy Practices

Click to Sign

Click to Sign

Financial Policy

Financial Policy

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Welcome to Blum-Nico Oral Surgery Associates
www.BlumNico.com

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