Lynn Oral Surgery

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In case of emergency

Contact:

Phone / Relation

Who will be responsible for your account?

Self Spouse Father Mother Other

Who will be responsible for your account

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

Are you a student?

Full Time Part Time Not a student

School Information

School Name

School Address

City/State/ZIp

Primary Dental Insurance Company

Employer / Business

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

S.S. # / Tel.

Insured Party Address

City / State / Zip

Primary Medical Insurance Company

Employer / Business

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

S.S. # / Tel.

Insured Party Address

City / State / Zip

Do you have secondary dental or medical insurance?

Yes No

Secondary Dental Insurance Company

Employer / Business

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

S.S. # / Tel.

Insured Party Address

City / State / Zip

Secondary Medical Insurance Company

Employer / Business

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

S.S. # / Tel.

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

Note: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding additional methods of birth control.

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

Medication #15

Medication #16

Medication #17

Medication #18

Medication #19

Medication #20

Medication #21

Please list any other medications or antibiotics you are allergic to

Medication / Antibiotic Allergy #1

Medication / Antibiotic Allergy #2

Medication / Antibiotic Allergy #3

Medication / Antibiotic Allergy #4

Conclusion

Is there any condition concerning your health that the Doctor should be told about?

Yes No

Do you wish to speak to the Dr. 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?

Yes No

If Yes, What type?

Automobile

Work related

Other

Date of Injury

Insurance Company / Claim #

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)

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

PATIENT FINANCIAL POLICY

PATIENT FINANCIAL POLICY - EFFECTIVE SEPTEMBER 1, 2020
Thank you for choosing us as your Oral Surgery provider. The following is a statement of our Financial Policy:

FULL PAYMENT OF PATIENT OBLIGATIONS IS DUE AT TIME OF SERVICE
We accept cash, checks, credit cards, and debit cards

It is the policy of this office to help keep your health care costs as low as possible. To do this, we need to keep our billing costs to a minimum. Please help us in the following ways:
1.   Always bring your current health insurance card to the office
2.   Please notify us at the time of check-in of any changes in insurance
3.   Please pay your co-pay or deductible balance and co-insurance amount at the time of service
4.   You will be expected to pay in full if:
a You do not have insurance
b.   our oral surgery practice does not participate with your health plan
c.   You are unable to present a valid member identification card from your insurance carrier at the time of your visit, or
d.   We are unable to verify your insurance coverage

You should receive a bill for any other patient responsibility within 30 days, and/or an explanation of benefits {EOB or EOP) from your insurance company within 45 days of your visit. if you do not, we suggest that you contact your insurance plan to determine benefits, as they may not have made payment. Payment not received within 90 days may be transitioned to patient responsibility and you may be required to make other payment arrangements.

INSURANCE: Your insurance policy is a contract between you and your insurance company. We are not a party to that contact. In the event that we do not accept assignment of benefits please be aware that some, and perhaps all, of the services provided may be noncovered services under your plan and will be 100% responsible for these charges. It is your responsibility to:
1.   Ensure our office actively participates with your insurance carrier
2.   Know your benefit coverage, as well as your dependents, prior to receiving services
3.   Make sure that all individuals on your policy have the correct primary care physician selected at your insurance company, as this is the #1 reason why claims are denied
4.   Ensure that all pre-approval requirements are met to avoid denials or out-of-network benefits

Please remember that we must receive your billing information at the time of each visit in order to meet claims submission guidelines set by your insurance plan. If either the practice or the plan fails to receive accurate information to process your claim, you will be held responsible.

We will not be held liable for ensuring the accuracy of your insurance information, including, but not limited to, verifying current coverage and eligibility, obtaining authorizations, or confirming co-pay, co-insurance, and/or deductible information. Regarding insurance plans where we are a participating provider, all co-pays and deductibles are due at the time of treatment. In the event that your insurance coverage relates to a plan where we are not a participating provider, you will be 100% responsible for all charges incurred.

To summarize, your financial responsibility pertains to:
1.   Denied and non-covered services
2.   Services deemed not medically necessary by your insurance company
3.   Co-payments, deductibles, and co-insurance
4.   Pended claims due to lack of patient and/or guarantor information
5.   Non-insurance and/or out-of-network benefits

CO-PAY and CO-INSURANCE: We are required by our insurance contracts to collect all co-pays and other patient responsible amounts at the time of service.

DEDUCTIBLES: lf you have not met your deductible for the year, you will be asked for your co-pay at the time of your visit, and you will receive a statement with additional balances after your visit. It is too difficult to determine which services are applied to your deductible at the time of your visit, as this varies by health plan and your specific contract with your insurer.

SELF-PAY PATIENTS: Full payment is expected at the time of service. Payment plans are available, but you must set this up prior to the time of your visit.

RETURNED CHECKS: There is a $25 fee for any checks returned by the bank. This fee may change as bank fees change. Any check over $1000 will be processed as EFT (electric funds transfer) on the same day. If there aren’t sufficient funds you may be subject to bank and collection fees by Electronic Payment Systems, who handles all EFT transfers. Checks under $1000 may be subject to processing via EFT as well and same bank/collection fees may apply.

MISSED APPOINTMENTS: Unless cancelled at least 48 hours in advance, we reserve the right not to reschedule your appointment.

COLLECTIONS: Failure to pay account balances within 30 days from initial billing will result in interest charges up to the maximum allowed by law. Any past due balance not paid will be turned over to a collection agency after 90 days. This will affect your credit record. Any charges and fees resulting from this action, including collection agency fees, will be added to your account balance and will be your responsibility. In the event that the bill remains unpaid and litigation ensues for collection of sums due, this office shall be entitles to reasonable attorney fees and court costs.

LAB/X-RAY/DIAGNOSTIC SERVICES: You may receive a separate bill for medical care that includes lab, X-ray, or other diagnostic services from another facility. You are financially responsible for any co-pay or balance due for these services if they are not reimbursed by your insurance.

STATEMENTS: lf you have a balance on your account. We will send you a statement. It will show separately the previous balance and any new charges to the account, and any payments or credits applied to your account during the month.

PAYMENTS: Unless other arrangements are approved in advance, the balance on your statement is due and payable when the statement is issued, and past due if not paid within ten (10) business days.

DIVORCE: In the case of divorce or separation, the parent who presents the child (under 18) and/or is authorizing treatment for the child will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs; it is the authorizing parent’s responsibility to collect from the other parent. If the child is 18 or older, they are responsible for all charges regardless of any divorce/separation unless otherwise stated in the divorce decree.

COPIES AND TRANSFER OF RECORDS: There is a reasonable cost-based fee per state guidelines for copies of a medical record and completion of paperwork for FMLA. Our x-rays are now digital and will be printed to photo paper, or we can email x-rays if that method is preferred.

EFFECTIVE DATES: Once you have signed this agreement, you agree to all of the terms and conditions contained herein for this and any future visits, and the agreement will be in full force and effect.

I have read and understand the Financial Policy. I agree to assign insurance benefits to Salem Peabody Oral Surgery, Lynn Oral Surgery, North Boston Oral and Facial Surgery, or Melrose Oral Surgery whenever necessary. I also agree that if it becomes necessary to forward my account to a collection agency, in addition to the amount owed, I also will be responsible for the fee charged by the collection agency for costs of collections.

Signature of patient ( Parent or Guardian if Minor)

Click to Sign

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

Relationship:

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

√

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

Signature of patient (Parent or Guardian if Minor)

Click to Sign

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

Our Legal Duty

We are required by applicable federal and state law to maintain the privacy of your health information. We are absolutely aware of these responsibilities and will carry out these responsibilities without hesitation. We are also required to give you a Notice about our privacy practices, our legal duties and your rights concerning your health information. If you would like the complete Notice of Privacy Practices, please ask our front desk staff. We would be happy to give you these forms in their entirety.

I,_______________________________, understand my rights and understand that the doctors and staff of Salem-Peabody Oral Surgery, Lynn Oral Surgery, North Boston Oral and Facial Surgery, or Melrose Oral Surgery will respect my rights and carry out their responsibilities to the letter of the law.

Name

Signature of patient (Parent or Guardian if Minor)

Click to Sign

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

CONTROLLED SUBSTANCES PRESCRIPTION USE AND SAFETY INFORMATION

You have been prescribed opioid medication for management of you post surgical pain. The following is information about the medications you will be taking for pain management and to assure that you and your surgeon comply with all state and federal regulations concerning the prescribing of controlled substances. Your opioid medication is to be taken as needed in the immediate post-operative period with the intent of reducing moderate to severe pain related to your surgery. It is important that you understand the risks and benefits of using opioids to treat pain. Opioid drugs can be very useful, but have a high potential for misuse and addiction and are therefore closely controlled by the local, state, and federal government.

1. You should inform your doctor of your complete medical history and all medications you are taking, including herbal remedies, since opioid medications can interact with over-the-counter medications, and other prescribed medications, especially cough syrup that contains alcohol, codeine or hydrocodone.

2. Please advise your doctor if you have ever been diagnosed with Obstructive Sleep Apnea.

3. You doctor may discuss your pain management with other health care professionals and family members when it is deemed medically necessary in your doctor’s judgment. Your doctor will also obtain information from State controlled substances databases and other prescription monitoring programs.

4. You will be seen for regularly scheduled post-surgical follow up visits, and on an as needed basis, and given prescriptions for enough medication as judged appropriate through the peri-operative period.

5. Prescriptions for pain medicine or any other prescriptions will be provided only during an office visit or during regular office hours. No refills of any narcotic medications will be provided during the evening or on weekends.

6. You understand that if your prescription runs out early for any reason (for example, if you use more than prescribed), your doctor may elect NOT to prescribe extra medication for you.

7. You are responsible for keeping your pain medication in a safe and secure place, such as a locked cabinet or safe. You are expected to protect your medications from loss or theft. Stolen medications should be reported to the police and to your doctor immediately. If your medications are lost, misplaced or stolen, your doctor will NOT replace the medications.

8. You may not give or sell your medications to any other person under any circumstances. If you do, you may endanger that person’s health. It is also against the law.

9. Drug hoarding, or uncontrolled dose escalation is prohibited.

10. Acquisition of any opioid medication from other physicians (which includes emergency rooms) must be disclosed to your doctor. Duplicate or redundant opioid prescriptions will NOT be provided.

11. You should communicate fully to your doctor any side effects of the medications. This information allows your doctor to adjust your treatment accordingly.

12. You should not use any illicit substances, such as cocaine, marijuana, etc. while taking opioid medications. The use of illicit substances and the use of alcohol with opioid medications are contraindicated and can result in serious illness, injury, and or death.

13. There are side effects with opioid therapy, which may include, but not exclusively, nausea, vomiting, skin rash, constipation, sexual dysfunction, sleeping abnormalities, sweating, edema, sedation, or the possibility of impaired cognitive (mental status) and/or motor ability. Overuse and over dosing of opioids can cause decreased respiration (breathing) and possibly death. Drowsiness may occur when starting opioid therapy or when increasing the dosage. Refrain from driving a motor vehicle or operating dangerous machinery until such drowsiness disappears.

14. Physical dependence, addiction and/or tolerance can occur with the use of opioid medications.
• Physical dependence: If opioid medications are abused or not taken as directed, withdrawal syndrome can occur. Withdrawal syndrome symptoms could include, but not exclusively, sweating, nervousness, abdominal cramps, diarrhea, goose bumps, heart rhythm irregularities and alterations in one’s mood. It should be noted that physical dependence does not equal addiction.
• Addiction is a primary, chronic neuro-biologic disease with genetic, psychosocial and environmental factors influencing its development and manifestation. It is characterized by behavior that includes one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and cravings. This means the drug decreases one’s quality of life.
• Tolerance means a state of adaptation in which exposure to the drug induces changes that result in diminishing of the drug’s beneficial effects over time.

If you have a history of alcohol or drug misuse/addiction, you must notify the doctor of such history since the treatment with opioids for pain may increase the possibility of relapse. A history of addiction does not, in most instances, disqualify one for opioid treatment of pain, but starting or continuing a program for recovery is a must.

15. Please discuss with your doctor if you are currently in a drug rehabilitation program and/or are currently receiving Suboxone or Methadone treatment, as this could alter your response to, and impair the clinical benefits received from, opioid medications. Your pain clinic team should be involved for any adjustments and alterations of current medications required with your pain management plan.

By signing this document, I have read and understand the above information.

Signature of patient (Parent or Guardian if Minor)

Click to Sign

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

Lynn Oral Surgery

Main Header

Demographic Information

Patient Information

In case of emergency

Who will be responsible for your account

Spouse or other guarantor information (if different from above)

Insurance Information

General Insurance Information

School Information

Primary Dental Insurance Company

Primary Medical Insurance Company

Secondary Dental Insurance Company

Secondary Medical Insurance Company

Health History

Health History

Health History Part 2

Have you ever had, or do you currently have

This section is for women only

Medications / Allergies

Are you now taking

Please list any medications you are currently taking

Are you allergic to, or had a reaction to

Column2

Please list any other medications or antibiotics you are allergic to

Conclusion

Conclusion

Is there a FAMILY history of

Is this visit related to an accident?

Verification

Click to Sign

PATIENT FINANCIAL POLICY

Click to Sign

Authorization

Click to Sign

Our Legal Duty

Click to Sign

CONTROLLED SUBSTANCES PRESCRIPTION USE AND SAFETY INFORMATION

Click to Sign

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