Oral and Maxillofacial Associates

Main Header

PERSON RESPONSIBLE FOR PAYMENT, IF PATIENT IS UNDER THE AGE OF 18

Name

Relationship to Patient

Sex

Male Female

Date of Birth / Social Security #

Address

City / State / Zip

Home / Work / Mobile Phones

EMERGENCY CONTACT

Name

Relationship to Patient

Address

City / State / Zip

Home / Work / Mobile Phones

DENTAL INSURANCE

(if more than one Insurance Company,

check here

and an additional form will be supplied)

Self-Pay

Yes No

Insurance Company Name

Insurance Company Address

City / State / Zip

ID/Policy # / Phone #

POLICY HOLDER INFORMATION

POLICY HOLDER INFORMATION

Name

Date of Birth / Social Security #

Home / Mobile Phone #s

Address

City / State / Zip

Employer

Phone #

MEDICAL INSURANCE

(if more than one Insurance Company,

check here

and an additional form will be supplied)

Insurance Company Name

Insurance Company Address

City / State / Zip

ID/Policy # / Phone #

POLICY HOLDER INFORMATION

POLICY HOLDER INFORMATION

Name

Date of Birth / Social Security #

Home / Mobile Phone #s

Address

City / State / Zip

Employer

Phone #

FEES AND PAYMENTS

An estimate of the charges for any procedure or surgery required will be given to you upon request. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid by your insurance at the time services are rendered. We accept Cash, Personal Checks under $2,500.00, Cashier’s Checks over $2,500.00, Visa, MasterCard, Discover and American Express. We do not handle financing “in-house”, but we do have financing options available upon approval. All charges are your responsibility, whether the insurance company pays or not. You may reach the billing office at (405) 848-7994 with any questions or concerns.

Thank you for selecting OMA as your health care provider. We appreciate your trust in us and the opportunity to serve you.

This signature is my authorization for the release of information necessary to process my claim.

SIGNATURE OF PATIENT/LEGAL GUARDIAN:

Click to Sign

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

PATIENT MEDICAL HISTORY

Weight / Height / Age

Name of Physician

Phone

Name of Dentist

Phone

Are you under a physicians care?

Yes No

Date of last physical exam

Are there any limitations to your activities?

Yes No

MEDICATIONS / ALLERGIES

List allergies to drug/medications (such as penicillin, codeine, etc.);

List prescription medications (including birth control pills);

List non-prescription medications, diet pills, alcohol or recreational drugs used in the last seven (7) days (Aspirin, Ginkgo Biloba, St. John's Wort, allergy, cocaine, marijuana etc.);

List all previous surgeries/hospitalizations/anesthesia history (type and date):

Is there any other information about your health which we should know about or that you would like to discuss with the Doctor in private?

MEDICAL INFORMATION CERTIFICATION

I hereby certify that the information list above which I have provided regarding the medical history and status of

is completed, true, and correct and may be relied upon for all purposes by Oral and Maxillofacial Associates, Inc., their assistants, colleagues, staff, and employees, and any other persons treating or assisting in the treatment of the patient.

Patient (or legally authorized individual) Signature

Signature

Click to Sign

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

Financial Policy

Thank you for choosing us as your health care provider. The following is a description of our financial policy:

• The guarantor or person responsible for payment will be the patient if they are 18 or older. If the patient is a minor, the guarantor will be the guardian who brings them to their appointment.

• If you are insured, it is your responsibility to provide your insurance information to our office upon scheduling. If you are unable to provide it at the time of scheduling, you will need to provide it upon check-in.

• A fee is associated with the office visit/consultation and any imaging we take for diagnostic purposes. This will be billed to your insurance company if applicable and will be collected at surgery or billed to you once insurance has been processed.

• You are responsible for ensuring you are maximizing your insurance benefits by having services rendered by an in-network provider. We do our best to verify your network status prior to consultation but cannot guarantee this. If we are out-of-network, you will be notified at check-out and prior to surgery.
• Please note that we do not accept or file Medicare, HMO/DMO’s, Soonercare, or Tricare Medical

• Payment is due at the time services are rendered.
• We accept cash, checks, Visa, MasterCard, Discover and American Express.
• We will be happy to assist you with applying for financing should you so desire. We do not handle any financing “in house” but we do have financing available through CareCredit and PrimaHealth.
• We reserve the right to collect in full before services are rendered.
• If your total is over $3,500.00 we require payment be made by card, cashier check or money order.

• All charges are your responsibility whether the insurance company pays or not.
• Not all services are a covered benefit. Benefits may vary depending on different insurance plans. It is your responsibility to verify your insurance coverage.
• Fees for non-covered services, deductibles and co-payments are due at the time of treatment.
• Services listed as ‘By Review’ with your insurance company will be collected in full at the time of service. If your insurance company pays for the service a refund may be issued.
• The amount we are collecting is an estimate based on the benefits available the day it is verified. It is not a guarantee of payment or benefits once the claims are received and processed. You may be responsible for charges beyond the quote given to you.
• If your insurance company does not pay your claim within a reasonable time frame, we may require you to follow up with your insurance and/or pay the balance due.

• Unless you are insured by an insurance group in which our doctors are participating members, or if you are double insured (for the procedure being performed), it’s our policy to collect 100% payment at the time services are rendered.

• We understand that temporary financial problems may affect timely payment of your balance. We ask that you speak with the Insurance Coordinator if you encounter such problems. You may reach the Insurance Coordinator by calling the office you are scheduled at.

By signing below, you agree to the financial policy listed above.

Patient or Guarantor’s Signature

Click to Sign

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

CONSENT FOR DISCLOSURE OF PROTECTED HEALTH CARE INFORMATION

My protected health information (PHI) is private and confidential and I understand OMA works very hard to protect my privacy and preserve the confidentiality of my PHI. I understand OMA may use and disclose my PHI to help provide health care, to handle billing and payment, to consult with my driver if needed, and to take care of other health care operations. Also, I understand that sometimes the law may require the release of this information without my permission.

My signature below means that I agree to allow my doctor to use and disclose my PHI to carry out treatment, payment, and healthcare operations as stated above. I understand that unless I list individuals or organizations outside OMA’s health care operations under the HIPAA section below, OMA will not be permitted to speak with them regarding my PHI.

Patient (or Legally Authorized Individual) Signature

Click to Sign

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

HIPAA

I hereby authorize Oral and Maxillofacial Associates, LLC to release the following information to the following individual(s):

Information to be shared:

Entire Medical Record

Yes No

Billing Information

Yes No

Other

Yes No

Parent (or Legally Authorized Individual) Signature

Click to Sign

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

PATIENT RIGHTS

OMA has a detailed document called the “Notice of Privacy Practices.” It contains more information about the policies and practices protecting my privacy. I understand I have the right to read the “Notice” before signing this agreement. OMA may update this “Notice” at any time and if I ask, OMA will provide me with the most current “Notice”.

My signatures above and below indicate that I have been given the opportunity to review a current copy of OMA’s “Notice” and I understand by voluntarily signing these authorizations the following:
• I authorize the use or disclosure of my PHI as described above for the purpose(s) listed above.
• I have the right to withdraw permission for the release of my information. If I sign this authorization to use or disclose information, I can revoke this authorization at any time. The revocation must be made in writing to the person/organization disclosing the information and will not affect information that has already been used or disclosed.
• I have the right to receive a copy of this authorization.
• I understand that unless the purpose of this authorization is to determine payment of a claim for benefits, signing this authorization will not affect my eligibility for benefits, treatment, enrollment or payment of claims.
• I understand I may change this authorization at any time by writing to the person/organization disclosing my PHI.
• I understand I cannot restrict information that may have already been shared based on this authorization.
• Information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer be protected by the Privacy Regulation.

Unless revoked or otherwise indicated, these authorization’s automatic expiration date will be one year from the date of my signature.

Patient (or Legally Authorized Individual) Signature

Click to Sign

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

truForm by PBHS

Oral and Maxillofacial Associates

Main Header

Patient Information

PATIENT INFORMATION

Responsible Party

PERSON RESPONSIBLE FOR PAYMENT, IF PATIENT IS UNDER THE AGE OF 18

Emergency Contact

EMERGENCY CONTACT

Insurance Information

DENTAL INSURANCE

POLICY HOLDER INFORMATION

MEDICAL INSURANCE

POLICY HOLDER INFORMATION

Fees and Payments

FEES AND PAYMENTS

Click to Sign

Patient Medical History

PATIENT MEDICAL HISTORY

HAVE YOU EVER HAD ANY OF THE FOLLOWING

Medications / Allergies

MEDICATIONS / ALLERGIES

Medical Information Certification

MEDICAL INFORMATION CERTIFICATION

Click to Sign

Conclusion

Financial Policy

Click to Sign

CONSENT FOR DISCLOSURE OF PROTECTED HEALTH CARE INFORMATION

Click to Sign

HIPAA

Click to Sign

PATIENT RIGHTS

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.

Oral and Maxillofacial Associates

Main Header

Patient Information

PATIENT INFORMATION

Responsible Party

PERSON RESPONSIBLE FOR PAYMENT, IF PATIENT IS UNDER THE AGE OF 18

Emergency Contact

EMERGENCY CONTACT

Insurance Information

DENTAL INSURANCE

POLICY HOLDER INFORMATION

MEDICAL INSURANCE

POLICY HOLDER INFORMATION

Fees and Payments

FEES AND PAYMENTS

Click to Sign

Patient Medical History

PATIENT MEDICAL HISTORY

HAVE YOU EVER HAD ANY OF THE FOLLOWING

Medications / Allergies

MEDICATIONS / ALLERGIES

Medical Information Certification

MEDICAL INFORMATION CERTIFICATION

Click to Sign

Conclusion

Financial Policy

Click to Sign

CONSENT FOR DISCLOSURE OF PROTECTED HEALTH CARE INFORMATION

Click to Sign

HIPAA

Click to Sign

PATIENT RIGHTS

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.