Cardinal Oral and Maxillofacial Surgery Associates

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PATIENT REGISTRATION

Payment information:

How will patient be paying for the services rendered?

Cash Credit Card Check

Person responsible for payment –only if patient is a minor (under 18)

Full name

Relation to patient

Address

Home phone / Work phone

Cell phone

Soc. Sec. # / Driver's License #

Dental Insurance (if none, write "none")

Name of Subscriber

Subscriber's Relation to Patient:

self spouse parent step-parent other

Subscriber's Birth Date / Subscriber's Soc. Sec. #

Name of Insurance Company / Phone

Claims Address

Dental Ins. Policy # / Dental Ins. Group #

Subscriber's Employer / Phone

Primary Medical Insurance (if none, write “none”)

Name of Subscriber

Subscriber’s Relation to Patient:

self spouse parent step-parent other

Subscriber's Birth Date / Subscriber's Soc. Sec. #

Name of Insurance Company / Phone

Claims Address

Medical Ins. Policy # / Medical Ins. Group #

Subscriber's Employer / Phone

Secondary Medical Insurance (if none, write "none")

Name of Subscriber

Subscriber’s Relation to Patient:

self spouse parent step-parent other

Subscriber’s Birth Date / Subscriber's Soc. Sec. #

Name of Insurance Company / Phone

Claims Address

Medical Ins. Policy # / Medical Ins. Group #

Subscriber's Employer / Phone

For PATHOLOGY Patients Only:

Please note that there may be additional charges separate from our office charges due to outside lab fees. Patients are responsible for these charges.
Medicare information is only requested from pathology patients in order to relay this information to the laboratory to which your biopsy will be sent. Cardinal Oral & Maxillofacial Surgery Associates is NOT a MEDICARE provider, and therefore cannot submit claims to Medicare for our services. Detailed receipts can be provided to you for self-filing of your claim to Medicare upon request.

ALL PATIENTS:

By signing below, Responsible Party acknowledges the above information as being correct and agrees to notify our office as changes may occur.
Responsible Party also agrees to pay for any services rendered in full at the time these services are rendered. The signature below serves as a “signature on file” authorizing our office to release any medical/dental records as required by law or for appropriate care with other providers and to process any insurance claims on behalf of insured, at insured’s request.
By signing below, Responsible Party acknowledges receipt of the Financial and Insurance Policy. Should Responsible Party not pay for services rendered, Responsible Party shall be liable for any late charges or collection fees that may result.

ALL PATIENTS

Patient/Guardian Signature

Click to Sign

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

Guarantor Signature

Click to Sign

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

Women

Are you pregnant or trying to become pregnant?

Yes No

Do you have problems associated with your menstrual period?

Yes No

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

Chief Dental Complaint:

Conclusion

I have read and understand the above. Any questions I had about this form have been answered and I understand the answers. I understand it is my responsibility to fill out the form correctly and completely.

Patient’s Signature:

Click to Sign

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

The medical staff has reviewed this form thoroughly in my presence.

Acknowledgment of Receipt of Notice of Patient Privacy Practices

By signing this written Acknowledgment of Receipt of Notice of Patient Privacy Practices, I hereby expressly acknowledge my receipt of the Notice of Patient Privacy Practices for Cardinal Oral and Maxillofacial Surgery Associates.

, hereby acknowledge that I have

received a copy of the Notice of Privacy Practices. I have been given the opportunity to ask any questions I may have regarding this Notice.

I hereby authorize the above listed physician and/or other staff members to discuss my issues with the following persons:

Name

Relationship / Phone

Name

Relationship / Phone

I further authorize Cardinal Oral Surgery to release my health care information (including x-rays) to any dentist, physician or medical facility that may request such information in relation to my care at Cardinal Oral Surgery.

I understand I have the right to:
• Receive a copy of this authorization for my records.
• Revoke this authorization at any time by notifying Cardinal Oral Surgery in writing.

This authorization will remain in effect until otherwise notified.

Signature of Patient/Legal Representative

Click to Sign

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

truForm by PBHS

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Patient Information

Patient Information

Payment Information

Payment information:

Insurance Information

Dental Insurance (if none, write "none")

Primary Medical Insurance (if none, write “none”)

Secondary Medical Insurance (if none, write "none")

For PATHOLOGY Patients Only:

ALL PATIENTS:

Click to Sign

Click to Sign

Medical History

Medical History Form

ALLERGIES: Are you allergic to or have you had a reaction to:

Women

Chief Dental Complaint:

Conclusion

Click to Sign

Notice of Privacy Practices

Acknowledgment of Receipt of Notice of Patient Privacy Practices

Click to Sign

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Main Header

Patient Information

Patient Information

Payment Information

Payment information:

Insurance Information

Dental Insurance (if none, write "none")

Primary Medical Insurance (if none, write “none”)

Secondary Medical Insurance (if none, write "none")

For PATHOLOGY Patients Only:

ALL PATIENTS:

Click to Sign

Click to Sign

Medical History

Medical History Form

ALLERGIES: Are you allergic to or have you had a reaction to:

Women

Chief Dental Complaint:

Conclusion

Click to Sign

Notice of Privacy Practices

Acknowledgment of Receipt of Notice of Patient Privacy Practices

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.