Welcome to Johnson Oral Facial Surgery

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In case of emergency

Name

Phone / Relation

Who will be responsible for your account

Name / Social Security Number

Birth Date / Age

Responsible Party Phone

Email / Driver's License

Address

Spouse or other guarantor information (if different from above)

Name / Relation to Patient

Birth Date / Social Security # / Phone

Mailing Address

Primary Dental Insurance Information

Employer / Business

Business Address

City / State / Zip

Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Ins. Company Address

City / State / Zip

Phone Number

Group

Insured Party Name

Relation / Birth Date

Insured Party Sex

Male Female

S.S. # / Tel.

Address

City / State / Zip

Primary Medical Insurance Information

Employer / Business

Business Address

City / State / Zip

Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Ins. Company Address

City / State / Zip

Phone Number

Group

Insured Party Name

Relation / Birth Date

Insured Party Sex

Male Female

S.S. # / Tel.

Address

City / State / Zip

Are you now taking

Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Xarelto, Eliquis, Fish oil)

Yes No

Have you ever taken diet pills

Yes No

Any natural product, herbal supplement or homeopathic remedy

Yes No

Are you taking, or have you ever taken bone density meds, RANKL inhibitors or bisphosphonates such as Prolia, Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Reclast, Xgeva, or Evista in the past 12 years?

Yes No

Please list any medications you are currently taking

Medication #1

Medication #2

Medication #3

Medication #4

Medication #5

Medication #6

Medication #7

Medication #8

Medication #9

Medication #10

Medication #11

Medication #12

Please list all other medications:

Is there a family history of

Cancer

Yes No

Heart Disease

Yes No

Diabetes

Yes No

Anesthesia Problems

Yes No

Verification

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.

Signature of patient (Parent or Guardian if Minor)

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

AUTHORIZATION

I authorize my surgeon and his / 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.

√

I permit the office to communicate with me via text message on my cell phone.

Signature of patient (Parent or Guardian if Minor)

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

JOHNSON ORAL FACIAL SURGERY FINANCIAL POLICY

Thank you for choosing Johnson Oral Facial Surgery. We are committed to providing the highest quality care at a reasonable cost. With rising healthcare expenses, we will make every effort to keep costs at a minimum. However, we will not sacrifice quality and patient care to reduce costs. In efforts to provide complete transparency, we ask you to read and sign our financial policy prior to treatment.

• You are responsible for your charges: Patients or their legal guardian are responsible for all charges incurred during treatment and must pay for services. We will file your insurance claim as a convenience to our patients, but our relationship is with our patients and not their insurance company. You remain responsible for your bill.
• Payment for service: Payment is required at the time that the service is provided. If you are not covered by insurance, you must pay in full for all charges at the time of service unless prior arrangements have been made in our office.
• If you do not have insurance: Payment in full is expected at time of service. A payment plan or third party financing is available through the healthcare financing program, CareCredit.
• If you have insurance: As a valued service to you, we will investigate your insurance benefits, estimate your out-of-pocket costs and file claims on your behalf.
• You must pay for estimated out-of pocket expenses, such as estimated co-payments, deductibles, non-covered services or services requiring further review by your insurance carrier before treatment is initiated.
• To determine the amount that might be paid by your dental insurance, we can file a written pre-treatment estimate to your dental carrier. Most carriers require 4-6 weeks to complete this request, so treatment will be delayed. If you receive additional dental treatment before the scheduled procedure in our office, your estimated remaining benefits could be less or non-existent. Medical insurance carriers will not provide written pre-treatment estimates. They will only inform us if you have benefits and if the services might be covered.
• An insurance estimate is not a guarantee that your insurance company will pay exactly as estimated. Your insurance company determines the final amount paid at the time the claim is processed.
• Verification of benefits is not a guarantee of payment by the insurance company. Final determination is made by the insurance company at the time the claim is processed.
• Payment in full is expected no longer than 90 days after your claim has been filed by us. Insurance payments are supposed to be made by insurance companies within 30 days of filing. However, if your insurance company has not paid within 90 days, you will need to contact your insurance company to investigate claim status. If your payment is not received within 90 days of filing or if your claim is denied, you will need to pay the balance in full at that time. The payment will be applied to an authorized credit card or may be paid by check. A service charge of 1.5% per month will be added to your account if payment extends beyond 60 days from the date the claim was filed.
• We will cooperate with your insurance company to assist with processing your claim. Please do not submit additional claims or information to the insurance company unless specifically requested.
• Your insurance policy is a contract between you and your insurance company. The doctors are not part of the contract. Therefore, all charges incurred are your responsibility. You are responsible for payment whether or not your insurance company pays.
• Emergency patients: Patients having emergency surgery must pay in full with credit card or cash for all charges before services are rendered.
• Medicare: Dental procedures are not covered by Medicare. We are not Medicare providers, but if you need a procedure that is considered medical treatment, you can have the procedure in our office if you sign a private contract.
• Minors: The parent or guardian accompanying a minor is responsible for payment of services. Regardless of insurance coverage, patients age 18 and older are responsible for payment unless a parent accompanies them to the initial appointment and signs this agreement.
• Divorce situations: The parent who brings the child to the initial appointment is responsible for all charges incurred during treatment, regardless of who provides insurance coverage.
• Returned checks/missed appointments: A $50 service will be charged for returned checks, and missed exams or check-ups not cancelled at least 24 hours in advanced. A $100 service will be charged for missed surgical procedures not cancelled at least 24 hours in advanced.

I have read the above, understand and agree to the above terms and conditions, and I agree to be responsible for total payment of my account:

Signature of patient (Parent or Guardian if Minor)

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

I authorize my insurance benefits be paid directly to Johnson Oral Facial Surgery.

Signature of patient (Parent or Guardian if Minor)

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

JOHNSON ORAL FACIAL SURGERY NOTICE OF PRIVACY PRACTICES

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.

When you receive treatment or benefits from Johnson Oral Facial Surgery, we receive, create and maintain information about your health, treatment, and payment for services. We will not use or disclose your information without your written authorization (permission) except as described in this notice.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

We may use and disclose your health information without your authorization for treatment, payment, educational material and health care operation purposes. Examples include but are not limited to:

• Using or sharing your health information with other health care providers involved in your treatment or with a pharmacy that is filling your prescription.
• Using or sharing your health information with your health plan to obtain payment for services or using your health information to determine your eligibility for government benefits in a health plan.
• Using or sharing your health information to run our business, to evaluate provider performance, to educate health professionals, and / or educate other patients.
• Administrative activities.

We may share your health information with our business associates who need the information to perform services on our behalf and agree to protect the privacy and security of your health information according to agency standards.

We may use or share your health information without your authorization as authorized by law for our patient directory, to family or friends involved in your care for purposes of notifying your family or friends of your location and status in an emergency situation.

We may use and disclose your health information without your authorization to contact you for the following activities, as permitted by law and agency policy: providing appointment reminders; describing or recommending treatment alternatives; providing information about health-related benefits and services that may be of interest to you; or advertising.

We may also use and disclose your health information without your authorization for the following purposes:

• To comply with workers compensation laws and similar programs;
• To alert appropriate authorities about victims of abuse, neglect, or domestic violence; if the agency reasonably believes you are a victim of abuse, neglect, or domestic violence we will make every effort to obtain your permission, however, in some cases we may be required or authorized to alert the authorities;
• For research purposes;
• To create or share de-identified or partially de-identified health information (limited data sets);
• For judicial and administrative proceedings such as responding to a subpoena or other lawful order;
• For incidental disclosures such as when information is overheard in a waiting room despite reasonable steps to keep information confidential; and
• As otherwise required or permitted by local, state, or federal law.

YOUR PRIVACY RIGHTS
Although your health record is the property of Johnson Oral Facial Surgery, you have the right to:

• Inspect and copy your health information, including lab reports, upon written request and subject to some exceptions. We may charge you a reasonable, cost-based fee for providing records as permitted by law.
• Receive confidential communications of your health information, such as requesting that we contact you at a certain address or phone number. You may be required to make the request in writing with a statement or explanation for the request.
• Request that we restrict how we use and disclose your health information for treatment, payment, and health care operations, or to your family and friends. We are not required to agree to your request, except when you request that we not disclose information to your health plan about services for which you paid with your own money in full.
• Obtain a paper copy of this notice upon request.

You may make any of the above requests in writing to:
Johnson Oral Facial Surgery
7001 Preston Road, Suite 125
Dallas, Texas 75205

OUR DUTIES
We are required to provide you with notice of our legal duties and our privacy practices with respect to your health information. We must maintain the privacy of information that identifies you and notify you in the event your health information is used or disclosed in a manner that compromises the privacy of your health information.

We are required to abide by the terms of this notice. We reserve the right to change the terms of this notice and to make the revised notice effective for all health information that we maintain. We will post revised notices on our public website at www.oralsurgeryofdallas.com. You may request a copy of the revised notice at the time of your next visit.

COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint by contacting: Office for Civil Rights, Region VI, U.S. Department of Health and Human Services, by mail at 1301 Young St., Suite 1169, Dallas, Texas 75202; or by telephone at (800) 368-1019, (214) 767-0432 (fax), or (800) 537-7697 (TDD).

For complaints about a violation of your right to confidentiality by an alcohol or drug abuse treatment program, contact the United States Attorney’s Office for the judicial district in which the violation occurred.

We will not retaliate against you for filing a complaint.
JOFS Privacy Notice Effective Jan 1, 2022

Signature of patient (Parent or Guardian if Minor)

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

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Welcome to Johnson Oral Facial Surgery

Main Header

Demographic Information

Patient information

In case of emergency

Who will be responsible for your account

Spouse or other guarantor information (if different from above)

Insurance Information

Primary Dental Insurance Information

Primary Medical Insurance Information

Health History

Health History

Health History Part 2

Have you ever had or do you currently have...

Have you ever had or do you currently have...

Medications / Allergies

Are you now taking

Please list any medications you are currently taking

Are you allergic to or had a reaction to

Conclusion

Is there a family history of

Verification

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Welcome to Johnson Oral Facial Surgery

Main Header

Demographic Information

Patient information

In case of emergency

Who will be responsible for your account

Spouse or other guarantor information (if different from above)

Insurance Information

Primary Dental Insurance Information

Primary Medical Insurance Information

Health History

Health History

Health History Part 2

Have you ever had or do you currently have...

Have you ever had or do you currently have...

Medications / Allergies

Are you now taking

Please list any medications you are currently taking

Are you allergic to or had a reaction to

Conclusion

Is there a family history of

Verification

Click to Sign

Click to Sign

Click to Sign

Click to Sign

Click to Sign

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