South Florida Dental Implant and Facial Surgery Center

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In Case of Emergency

Contact:

Phone / Relation

Who will be responsible for your account?

Self Spouse Father Mother Other

If other, please specify:

Who will be responsible for your account

Name / Social Security Number

Birth Date / Age

Responsible Party Phone

Email / Driver's License

Address

Employer / Phone

Spouse or Other Guarantor Information (if different from above)

Name / Relation to Patient

Birth Date / Social Security # / Phone

Address

Employer / Business Name

Do You have secondary Dental or Medical Insurance?

Yes No

PLEASE UPLOAD PICTURES OF THE FRONT AND BACK OF YOUR INSURANCE CARD AT SUBMISSION

Is this related to an accident?

Yes No

If Yes, What type?

Automobile

Work related

Other

Date of Injury

Insurance Company / Claim #

Attorney / Adjustor & Phone

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 list any medications you are currently taking

Medication #1

Medication #2

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Please list any allergies other than those listed above above:

Medication / Antibiotic Allergy #1

Medication / Antibiotic Allergy #2

Medication / Antibiotic Allergy #3

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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.

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

FEES & PAYMENTS We wish our patients to know that all professional services are rendered directly to the patient. We are happy to prepare all necessary forms to obtain your maximum benefits form your insurance company and file the claim on your behalf. However, insurance coverage is estimated and your actual indemnity may be less than estimat-ed. Your insurance carrier may help you by deferring a certain amount of these costs, but insurance is not a substitute for payment and the financial obligation to pay for your services, the amounts not covered by your insurance, and the request of refunds ultimately remains with you the patient. If for some reason the account should become delinquent, or if your insurance company requests refunds of prior paid fees, you agree to pay for all balances, rebilling charges, interest charged, collections costs, and attorney fees. 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.

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

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.

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AUTHORIZATION I authorize my surgeon and his / her designated staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis, education, and treatment planning. Furthermore, I authorize the taking of all x–rays, tests, and pictures 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

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

√

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

INFORMATION FOR MEDICARE PATIENTS
Our office is NOT A MEDICARE PROVIDER, so we are required to enter in what Medicare calls a “Private Contract”.

Therefore, neither this office nor I, the patient, can submit a claim to Medicare/Medigap or its agents for services provided here. Of course, I understand that I could go elsewhere to have treatment by a Medicare practitioner for whom Medicare payment could be made, and where I would not need to enter into such a private contract.

I am fully responsible for payment of services rendered here, and I understand that no Medicare reimbursement will be provided. Supplemental insurance providers may also deny payment for these services.

I understand that this office’s fees are not based or limited by Medicare guidelines under Section 1128 of the Social Security Act or pursuant to any other legal authority. This contract is effective upon signing and will remain in effect for 2 years, and renews automatically by you opting to still be our patient.

Signature of patient (Parent or Guardian if Minor)

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

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.\

PLEASE REVIEW IT CAREFULLY.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY:
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contct us using the information at the end of the Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION:
We use and disclose health information about you for treatment, payment, and healthcare operations. For Example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare; but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, domestic violence, or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

PATIENT RIGHTS:
Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $0.50 for each page, $6 per hour for staff time to locate and copy your health information, and postage if you want the copies to be mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the address listed at the end of this Notice for a full explanation of our fee structure.)

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations, and certain other activities, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement, except in an emergency.

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. {You must make your request in writing.} Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our website or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

USES AND DISCLOSURES OF HEALTH INFORMATION:
If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, you disagree with a decision we made about access to your health information, or in response to a request you made to amend or restrict the use or disclosure of your health information, or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed on this website. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact Officer ..........................DR. MICHEL MATOUK
Telephone .................................954-566-0300
Address ................................2600 East Commercial Blvd
Suite 200
Fort Lauderdale, Florida 33308

I hereby acknowledge that I have read and agree to the office’s Notice of Privacy Practices. I have been given the opportunity to ask any questions I may have regarding this Notice.

Signature of patient (Parent or Guardian if Minor)

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

truForm by PBHS

Main Header

Demographic Information

Patient information

Section Two

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

Secondary Dental Insurance Information

Secondary Medical Insurance Information

Is this related to an accident?

Health History

Health History

Health History Part 2

Have you had or do you currently have...

Have you had or do you currently have...

Women Only:

Medications / Allergies

Medications (Are you now taking...)

Are you allergic or had a reaction to:

Please list any medications you are currently taking

Please list any allergies other than those listed above above:

Verification

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Main Header

Demographic Information

Patient information

Section Two

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

Secondary Dental Insurance Information

Secondary Medical Insurance Information

Is this related to an accident?

Health History

Health History

Health History Part 2

Have you had or do you currently have...

Have you had or do you currently have...

Women Only:

Medications / Allergies

Medications (Are you now taking...)

Are you allergic or had a reaction to:

Please list any medications you are currently taking

Please list any allergies other than those listed above above:

Verification

Click to Sign

Click to Sign

Click to Sign

Click to Sign

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Click to Sign

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