Raleigh Oral Surgery & Dental Implants

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Health History

Last / First Name

Address

City / State / Zip

Home / Cell / Work Phone

Email Address

Occupation / Employer

SS# / Date of Birth

Gender/ Height / Weight

Whom may we thank for referring you to our office?

Primary Care Physician

Phone #

WOMEN:

Any elective surgery and anesthesia during pregnancy is potentially harmful to the developing fetus.Is there any chance you could possibly be pregnant?

Yes No

Date of Last Menstrual Period

Do you wish to consult with your physician about the possibility of pregnancy prior to this visit?

Yes No

Signature of Patient (or parent if patient is a minor)

Click to Sign

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

PATIENT CONSENT FORM

PATIENT CONSENT FORM

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information as is required to carry out:

Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)
Obtaining payment from third party payers (i.e. my insurance company)
The day-to-day healthcare operations of North Hills Implant & Oral Surgery

I have also been informed of and given the right to review and secure a copy of the Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my health protected information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most recent copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.

With whom (family members or friends) may we share information about your treatment and account:

Name/ Relationship to Patient

Emergency Contact Name

Relation to Patient/Phone #

I consent that Raleigh Oral Surgery & Dental Implants may leave messages regarding my account, including but not limited to financial information and appointments using the following contact information:

Home / Cell

Email Text

Printed Patient Name

Patient Signature

Click to Sign

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

If patient is a minor:

Patient Guardian Signature

Click to Sign

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

Patient Guardian Name

Relationship to Patient

PAYMENT OPTIONS

(Sign that you have read and agree to the above conditions)

Click to Sign

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

Raleigh Oral Surgery & Dental Implants

PAYMENT OPTIONS
NOTE: Our office accepts cashier’s checks, CareCredit®, Visa®, and Mastercard® for your convenience.

If you DO have dental insurance:
We assist our patients in filing primary dental insurance claims on your behalf. However, all estimated copayments, deductibles, and treatment not covered by your primary dental insurance company is the sole responsibility of the patient and is due the day of treatment. Patient is responsible for filing all secondary dental insurance and medical insurance. Please understand that you will ultimately be held responsible for any account balance resulting from any unanticipated circumstances regarding insurance coverage. Any account balance will be assessed a 1% late fee after 30 days and after 90 days will be assessed a $12.50 collections fee and will be turned over to a collections agency. If your insurance information is not collected at the time of service, we must collect payment in full. In this circumstance, we are able to file your insurance as long as you provide the information within 30 days from day of service. After 30 days, we are unable to file on your behalf.

In order to help you better understand the complexities of dental insurance, we would like to highlight that dental insurance was not designed to pay for all dental care. Most contracts have deductibles, limits and/or various degrees of copayment. All levels of payment by insurance companies, including allowed fees, usual and customary (UCR), are governed by the premiums paid by you on your behalf. They have nothing to do with the actual charges. Our fees are based upon a combination of our costs, our time, and our constant dedication to supplying our patients with a high level of dental care. The treatment recommended by our office is never based on what your insurance company will pay; your treatment should not be governed by your insurance contract. It should be ultimately understood that the dental insurance contract is between the insurance company and the patient/subscriber, who bears the ultimate financial responsibility. Financial estimates provided by us for any procedures are not a guarantee of your portion. The information gathered from your insurance company is not a guarantee of payment and claims are subject to review once received. Prior authorization of your treatment is also not a guarantee of payment. Your insurance company may deny some or all of the services provided regardless of prior approval. If payment from your insurance results in a refund, please allow 45 days from insurance settlement date for our office to process your refund.

We hope this information has been helpful. Please take the time to review your contract thoroughly so we may best serve you. As always, you may feel free to ask us any questions for clarification on services, billing, and insurance. Our staff is committed to assisting you in any way that we can.

Copayments, deductibles and estimated patient portion for services rendered are due in full the day of treatment.
*****We DO NOT accept personal checks*****

DO YOU HAVE MEDICARE

Yes No

If you currently have dental insurance, please fill out this information and return it to us so that we may file your claim on your behalf.

Insurance Carrier

Employer

Subscriber Name

Subscriber ID

Subscriber Date of Birth / Social Security #

Group #

Insurance Claims Address

City / State / Zip Code

Phone #

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If you DO NOT have dental insurance:

At Raleigh Oral Surgery & Dental Implants, our goal is to provide a high level of treatment without causing any financial hardships for our patients. Therefore, we have secured many different financial options for your convenience. In addition to cashier’s checks, we accept most major credit cards to pay for your treatment. Our payment plan provider is CareCredit, the leader in patient financing for healthcare. CareCredit offers many sensible payment options. You may apply for CareCredit by calling 800-365-8295 or by visiting the website at www.carecredit.com to apply online.

Payment for services rendered is due in full the day of treatment.

(Sign that you have read and agree to the above conditions)

Click to Sign

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

Our Treatment Coordinator is happy to meet with you to discuss your treatment plan and answer any questions you might have.

CANCELLATION POLICY: If you do need to reschedule or cancel your appointment, we require 24 hours notice.

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Raleigh Oral Surgery & Dental Implants

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Health History

Health History

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Health History (Cont.)

Health History (Cont.)

Women

WOMEN:

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Patient Consent

PATIENT CONSENT FORM

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Payment Options

PAYMENT OPTIONS

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Raleigh Oral Surgery & Dental Implants

Main Header

Health History

Health History

Please Circle Any of the Following Which You Currently Have or Have Had

Health History (Cont.)

Health History (Cont.)

Women

WOMEN:

Click to Sign

Patient Consent

PATIENT CONSENT FORM

Click to Sign

Click to Sign

Payment Options

PAYMENT OPTIONS

Click to Sign

Click to Sign

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