North Mississippi OMS Associates

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Patient Information

ACCOUNT #

Prefix

Mr. Mrs. Ms. Dr.

Name

Preferred Name

Birth Date / Age / Sex

Social Security Number

Street Address

City / State / ZIP

Mailing Address (if other than street address)

Email Address

Home / Cell Phone

Work Phone

Race

Referred by?

Have you been a patient in our practice?

Dentist

Physician

Orthodontist

Name of family member that has been a patient in our practice

In case of emergency, please contact

Contact:

Phone / Relation

Privacy

Our practice is obligated to protect the privacy of your health information. Therefore, we will not release information regarding your appointments, account information, insurance, etc. during telephone conversations, etc., to anyone, unless you authorize us to do so by printing the names of those people below. I hereby authorize NMOMSA to release information to myself and the following person or persons(ie: mother, father, spouse, etc.) and accept that NMOMSA does not have the ability to verify the identity of individuals who call requesting information.

Name / Relationship / Phone

Signature of Patient or Guardian (must be 18 or older)

Click to Sign

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

Guarantor/Fees and Payments (Must be present at appointment)

Who will be responsible for your account?

Self Spouse Father Mother Other

Person Responsible for Account Name

Cell Phone

Mailing Address

City / State / Zip

Social Security Number / BirthDate

Employer / Emp Phone

Regardless of form of payment, consult fees are due on the date of appointment. We will be glad to file for reimbursement with your insurance company after your appointment. An estimate of the charge for any procedure or surgery you may require will be given to you prior to the surgery after our insurance clerk checks your benefits. Remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. Remember, we file your insurance as a courtesy to you, and it is ultimately your responsibility to know your insurance benefits and deductibles. I hereby authorize payment to this doctor, names of the benefits otherwise payable to me and certify by signing that I am responsible for the balance of this account. Payments are due and payable at Creditor’s place of business as shown on the bills, statements, and at the Creditor’s home office at 1043 South Madison Extended, Tupelo, MS, 38801. If the account is referred to collections, the Debtor agrees to pay the Creditor an additional 33 1/3% of the principle balance to include attorney fees, collections fees, processing fee, court costs, pre-judgement costs, and any other associated fee with the collection of the debt. The Debtor consents to the jurisdiction of the Lee County, Mississippi, court system for enforcement of payment of this account. I agree that I am personally liable on all charges made on this account by any family members. I also authorize my employment location and status to be verified for the purpose of processing my bill for payment. I authorize the use of the phone numbers and other contact information I provide, including my cellular number, and any future number assigned to me, for calls, texts, emails, to include automated dialers, to contact me regarding my care and my account by this medical provider and this medical provider's business associates. This signature on file is my authorization for the use of this information to process my insurance claim and is authorization for verification of employment.

Signature of person responsible for account (must be 18 or older)

Click to Sign

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

Insurance

Is this related to an accident?

Yes No

Is this accident work related?

Yes No

Primary Insurance - Dental

Dental Ins. Name

Employer

Emp. Phone Number

Insured Party Name

Patient Relation

Insured Party Sex

Male Female

DOB / SS#

Primary Insurance - Medical

Medical Ins. Name

Employer

Emp. Phone Number

Insured Party Name

Patient Relation

Insured Party Sex

Male Female

DOB / SS#

Secondary Insurance - Dental

Dental Ins. Name

Employer

Emp. Phone Number

Insured Party Name

Patient Relation

Insured Party Sex

Male Female

DOB / SS#

Secondary Insurance - Medical

Medical Ins. Name

Employer

Emp. Phone Number

Insured Party Name

Patient Relation

Insured Party Sex

Male Female

DOB / SS#

Allergies

Please list any Food, Latex, and/or Drug Allergies or Sensitivities

Social History

Chewing Tobacco

Yes No

Quantity

Smoking Tobacco

Yes No

Quantity

Alcohol

Yes No

Quantity

Recreational Drugs

Yes No

What type

Quantity

Women Only, are you currently:

Pregnant or trying to get pregnant

Yes No

Delivery date

Nursing

Yes No

Using Oral Contraceptives

Yes No

Other

Past Family History

Is there a family history of:

Cancer

Diabetes

Heart Disease

Malignant Hyperthermia

Other

None

I understand the importance of a truthful Health History to assist the doctor in providing the best care possible. I certify that I have read and 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 surgeon, or any other member of his staff, responsible for any errors or omission that I have made in the completion of this form.

Signature of Patient or Guardian(must be 18 or older)

Click to Sign

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

NOTICE OF PRIVACY PRACTICE: NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT I hereby acknowledge that I have been given the opportunity to read a copy of this practice’s Notice of Privacy Practices. I have been given the opportunity to ask questions I may have regarding this Notice.

Signature of Patient or Guardian (must be 18 or older)

Click to Sign

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

Medical History

Check box if any conditions pertain to your health now or in the past. Check NONE if they do not apply.

Medications

Please list ALL medications that you take including: prescription, over-the-counter, herbal, dietary supplements, holistic remedies, vitamins, etc.

Separate Medication List Provided

Yes No

Medications Listed Below

Yes No

No Current Medications

Yes No

Medication #1

Medication #2

Medication #3

Medication #4

Medication #5

Medication #6

Medication #7

Medication #8

Name of Pharmacy

Location / Phone

North Mississippi OMS Associates

Main Header

Demographic Information

Patient Information

In case of emergency, please contact

Privacy

Click to Sign

Guarantor/Fees and Payments

Guarantor/Fees and Payments (Must be present at appointment)

Click to Sign

Insurance

Primary Insurance - Dental

Primary Insurance - Medical

Secondary Insurance - Dental

Secondary Insurance - Medical

Health History

Health History

Allergies

Social History

Women Only, are you currently:

Past Family History

Click to Sign

Click to Sign

Medical History

Medical History

NEUROLOGICAL

HEAD AND NECK

CARDIOVASCULAR

PULMONARY

STOMACH/INTESTINES

KIDNEY/LIVER

BLOOD/LYMPH

ENDOCRINE/IMMUNE

BONES/JOINTS

Medications

Medications

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