Indiana Oral & Maxillofacial Surgery Associates

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Who will be responsible for your account - Responsible person must be present to sign

Who will be responsible for your account?

Self Spouse Father Mother Other

Name / Social Security Number

Birth Date / Age

Responsible Party Phone

Email / Driver's License

Address

City/State/Zip

Employer / Phone

Spouse or other guarantor information (if different from above)

Name / Relation to Patient

Birth Date / Social Security # / Phone

Address

City/State/Zip

Employer / Business Name

Primary Dental Insurance Information

Employer

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

Phone / Social Security #

Insured Party Address

City / State / Zip

Primary Medical Insurance Information

Employer

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

Phone / Social Security #

Insured Party Address

City / State / Zip

Secondary Dental Insurance Information

Employer

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

Phone / Social Security #

Insured Party Address

City / State / Zip

Secondary Medical Insurance Information

Employer

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

Phone / Social Security #

Insured Party Address

City / State / Zip

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

Are you taking any kind of medication, drug, pills?

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

Medication #13

Medication #14

Please list any other medication you are allergic to

Medication Allergy #1

Medication Allergy #2

Medication Allergy #3

Medication Allergy #4

Medication Allergy #5

Medication Allergy #6

Conditions concerning health

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

Anesthesia Problems

Yes No

Is this visit related to an accident?

Is this related to an accident?

Yes No

If Yes, What type?

Automobile

Work related

Other

Date of Injury

Insurance company handling claim / Claim #

Name of attorney / adjustor & Phone

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)

Click to Sign

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

FEES & PAYMENTS

We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.

Signature of patient (Parent or Guardian if Minor)

Click to Sign

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.

Signature of patient: (Parent or Guardian if Minor)

Click to Sign

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.

Signature of patient (Parent or Guardian if Minor)

Click to Sign

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

Notice of Privacy Practices Acknowledgement

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.

Signature of patient (Parent or Guardian if Minor)

Click to Sign

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

SMS MESSAGING

I understand that Indiana Oral & Maxillofacial Surgery Associates uses SMS/texting to send appointment confirmations and appointment reminders to
patients. These are also used to contact patients in the event we cannot reach them via traditional phone calls. I hereby consent to receive SMS messages from Indiana Oral & Maxillofacial Surgery Associates.

Signature of patient (Parent or Guardian if Minor)

Click to Sign

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

Limited Patient Authorization for Disclosure of Protected Health Information

This form is for you to tell the office of Indiana Oral and Maxillofacial Surgery if you would like for us to be able to communicate with anyone other than yourself. (IE: Spouse, Adult Child, Relative, Friend, etc.)

Form must be signed and dated.

SSN (last four digits)

I am authorizing Indiana Oral and Maxillofacial Surgery to disclose or provide protected health information about me to the following listed individual (s).

Individuals name and relation to me

I authorize the practice to disclose the following protected health information about me to the person, or persons identified above

Entire patient record

or, check only those items of the record to be disclosed:

office notes

lab results, pathology reports

x-rays

financial history report (previous 3 years only)

or only send the following

Please indicate a date you would like this authorization to expire

or No expiration date needed

Select

You have the right to terminate this authorization at any time by submitting a written request to our Privacy Manager. Termination of this authorization will be effective upon written notice, except where a disclosure has already been made based on prior authorization.
The practice places no condition to sign this authorization on the delivery of healthcare or treatment.
We have no control over the person(s) you have listed to receive your protected health information. Therefore, your protected health information disclosed under this authorization may no longer be protected by the requirements of the Privacy Rule, and will no longer be the responsibility of the practice.

Patient or authorized representative signature

Click to Sign

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

You have the right to receive a copy of signed authorizations upon request.

Indiana Oral & Maxillofacial Surgery Associates

Main Header

Demographic Information

Patient information

Who will be responsible for your account - *Responsible person must be present to sign*

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

Health History

Health History

Health History Part 2

Have you had or do you currently have...

Social History and Habits (Have you, or do you currently...)

This section is for women only

Medications / Allergies

Medications (Are you now taking...)

Please list any medications you are currently taking

Are you allergic or had a reaction to:

Please list any other medication you are allergic to

Conclusion

Conditions concerning health

Is there a FAMILY history of

Is this visit related to an accident?

Verification

Click to Sign

FEES & PAYMENTS

Click to Sign

Click to Sign

AUTHORIZATION

Click to Sign

Notice of Privacy Practices Acknowledgement

Click to Sign

SMS MESSAGING

Click to Sign

Patient Disclosure

Limited Patient Authorization for Disclosure of Protected Health Information

Click to Sign

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