Perio & Implant Center of Silicon Valley

The Perio & Implant Center of Monterey Bay

Main Header

Jochen P. Pechak DDS MSD
Diplomate, American Board of Periodontology

Two locations to serve you

Silicon Valley
500 South Murphy Ave, Sunnyvale, CA 94086 • 408-738-3423

Monterey Bay
21 Upper Ragsdale Dr Ste 202, Monterey, CA 93940 • 831-648-8800

Who will be responsible for your account

(IF SELF, SKIP TO NEXT SECTION)

Self Spouse Father Mother Other

Responsible Party Name / S.S.#

Birth Date / Age

Phone Number

Address

City/State/Zip

Driver's Lic.#

Employer / Phone

Spouse or other guarantor information (if different from above)

Name

S.S.# / Birth Date

Address

City/State/ZIp

Phone Number

Employer / Phone

Primary Dental Insurance Company

Employer

Bus. Address

Phone / Plan Type

Ins. Co. Name

Address

Tel.

Group# / Name

Insured Party

Sex

Male Female

Birth Date / SSN

Member ID #

Phone / Driver's Lic. #

Secondary Dental Insurance Company

Employer

Bus. Address

Phone / Plan Type

Ins. Co. Name

Address

Tel.

Group# / Name

Insured Party

Sex

Male Female

Birth Date / SSN

Member ID #

Phone / Driver's Lic. #

Medication - Are you now taking...

Any kind of medication, drug, pills

Yes No

Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko Biloba)

Yes No

Have you ever taken diet pills? Any natural product, herbal supplement or homeopathic remedy

Yes No

Have you ever taken any bone density medications / Bisphosphonates (Aredia, Zometa, Fosamax, Actonel)

Yes No

Have you ever taken tranquilizers, sleeping pills, anti depressants and / or narcotics on a regular basis.

Please list any medications you are currently taking

Medication / Dosage / Frequency

IF YOU ARE HAVING SURGERY TODAY

Have you had anything to eat or drink in the last 6 hours?

Yes No

Who is driving you home?

Mobile Phone Tel.

Patient Concerns for Doctor

PLEASE USE THE COMMENT BOX PRESENTED BELOW TO INPUT ANY DETAILS REGARDING THE NEXT TWO QUESTIONS:

Is there any condition concerning your health that the Doctor should be told about?

Yes No

Do you wish to speak to the doctor privately about anything?

Yes No

Is there a FAMILY HISTORY of

Cancer

Yes No

Diabetes

Yes No

Heart Disease

Yes No

Anesthetic Problems

Yes No

IN CASE OF EMERGENCY, CONTACT

Name

Home / Bus.Tel.

THIS SECTION IS FOR WOMEN ONLY.

Is there a possibility of pregnancy?

Yes No

Expected delivery date

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

Please Note: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regard additional methods of birth control.

Conclusion

Financial Policy
Thank you for choosing the Perio & Implant Center. We are committed to providing exceptional state-of-the-art periodontal and implant specialty care. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our financial policy that we require you to sign prior to any treatment. We require full payment at the time of service. We accept cash, personal check, Visa, MasterCard and American Express.

Insurance
As a courtesy to you, we will complete and submit all insurance claims paperwork to your dental insurance, on your behalf. We are premium providers of Delta Dental and we will require all co-payments and deductibles at the time that services are rendered. In the event your insurance benefits coverage changes, it is your responsibility to notify us so that we may update your account. There is no guarantee of payment from your insurance company, even with pre-authorizations, for such reasons you are the responsible party to keep your account current and satisfy any unpaid balances. Occasionally your insurance company may send your reimbursement payment to The Perio & Implant Center, in that case there may be up to 45 days from receipt of payment for a reimbursement check to be issued to you.

Medical Billing Courtesy Agreement

understand that the Perio & Implant Center, Dr Jochen Pechak's team will, as a courtesy, file my medical insurance to see if they will cover any expenses of the procedure I am to receive. I also understand that if payment is received by myself (as the patient) or Perio & Implant Center, that a refund or credit up to the amount I paid will be issued and refunded, back to me. Any money above and beyond what I paid is to be retained by the Perio & Implant Center, Dr Jochen Pechak.

USUAL AND CUSTOMARY FEES
We charge usual and customary fees for our services. You are responsible for payment regardless of any insurance company's arbitrary determination of "usual and customary." Additional fees might be included in your cost, regardless of your estimate, if during the course of your treatment at the Perio & Implant Center; additional procedures are deemed necessary by Dr. Pechak for your periodontal treatment. All unpaid balances are due within 30 days, regardless of statement provided. Any unpaid balances beyond 90 days will incur an additional $50 processing fee, per month of delinquency, added to your account, and the account holder is responsible for any additional charges added to the account in the event that additional proceedings are necessary to satisfy unpaid balances. Parents (or guardians of a minor) are responsible for full payment at the time of service.

Medicare Private Contract
By signing this contract I understand and agree that I will not submit or request that a claim be submitted to Medicare or any of its agents for services provided by The Perio and Implant Center Jochen Pechak DDS MSD even if such services would be covered. I agree to be fully responsible for payment of services rendered and I understand that no claims will be submitted to Medicare and no Medicare reimbursement will be provided for these services. I understand that there are no limits specified by Medicare as to the amounts that may be charged by The Perio and Implant Center for services provided.

PATIENT SIGNATURE

Click to Sign

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

MISSED APPOINTMENTS
Unless cancelled with our office during office hours 72 hours in advance by voice during our business hours, and 7 days prior for any surgical appointments, we may charge for missed appointments. Please help us to serve you better by keeping scheduled appointments.

This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

Authorization
I authorize Dr. Pechak and his designated team to perform a periodontal 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, I authorize the release of any information acquired in the course of my examination

I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

I certify that I have read and I understood 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 Periodontist, Dr. Jochen P. Pechak, or any other member of his team, responsible for any errors or omissions that I have made in the completion of this form.

PATIENT SIGNATURE

Click to Sign

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

truForm by PBHS

The Perio & Implant Center of Monterey Bay

Main Header

Demographic Information

Patient Information

Responsible Party

Who will be responsible for your account

Spouse or other guarantor information (if different from above)

Insurance Information

Insurance / Payment Information

Primary Dental Insurance Company

Secondary Dental Insurance Company

Medications / Allergies

Medication - Are you now taking...

Allergies - Are you allergic to, or had a reaction to...

Please list any medications you are currently taking

Health History

Health History

Dental History

Health History Part 2

Have you had or do you currently have...

IF YOU ARE HAVING SURGERY TODAY

Patient Concerns for Doctor

Is there a FAMILY HISTORY of

IN CASE OF EMERGENCY, CONTACT

THIS SECTION IS FOR WOMEN ONLY.

Conclusion

Conclusion

Click to Sign

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.

The Perio & Implant Center of Monterey Bay

Main Header

Demographic Information

Patient Information

Responsible Party

Who will be responsible for your account

Spouse or other guarantor information (if different from above)

Insurance Information

Insurance / Payment Information

Primary Dental Insurance Company

Secondary Dental Insurance Company

Medications / Allergies

Medication - Are you now taking...

Allergies - Are you allergic to, or had a reaction to...

Please list any medications you are currently taking

Health History

Health History

Dental History

Health History Part 2

Have you had or do you currently have...

IF YOU ARE HAVING SURGERY TODAY

Patient Concerns for Doctor

Is there a FAMILY HISTORY of

IN CASE OF EMERGENCY, CONTACT

THIS SECTION IS FOR WOMEN ONLY.

Conclusion

Conclusion

Click to Sign

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.