Patient Registration & Health History

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Please complete the following confidential information:

Reason for today's visit

Dentist

Medical Doctor

Referred By

Patient's Name

Marital Status

Married Single Divorced Other

Sex / Date of Birth / Social Security Number

Male Female

Address

Home / Cell Phone

Employer / Work Phone

E-Mail Address

Emergency Contact

Dental Insurance Information

(insurance card MUST be provided)

INS Company

ID / Group

Phone

Subscriber's Name

Sex / Relation

Male Female

Subscriber's Address

Subscriber's Date of Birth

Subscriber's Social Security Number

Medical Insurance Information

(insurance card MUST be provided)

INS Company

ID / Group

Phone

Subscriber's Name

Sex / Relation

Male Female

Subscriber's Address

Subscriber's Date of Birth

Subscriber's Social Security Number

Person Responsible For Account

(person MUST be present)

Name

Relation

Address

Home / Cell Phone

Driver's License Number / Work Phone

Social Security Number / Date of Birth

Assignment & Release

I acknowledge and agree that payment for services rendered is due at the time that such service is performed and that payment or payment arrangements must be made in accordance with terms of the financial policy of East Georgia Center for OFS, which is expressly made a part of the agreement and I acknowledge receiving and reading a copy of the financial policy.

I authorize payment of benefits to East Georgia Center for OFS for services rendered under the terms of my insurance policy, but not to exceed the balance due of my account and for East Georgia Center for OFS to release any medical or other information necessary to process insurance claims. I further authorize photocopies of this form to be as valid as the original.

I acknowledge East Georgia Center for OFS had made available to me their Notice of Privacy Practices according to 1996 HIPAA legislation. 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:-------------

Women Only

Are you pregnant?

Yes No

Is there a chance you might be pregnant?

Yes No

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

Antibiotics may interfere with the action of Oral Contraceptives (OC). It is recommended that you use additional contraceptive precautions while taking the medicine for the following seven (7) days.

I understand the importance of a truthful and complete Health History to assist my doctor in providing the best care. I verify that the information provided is true and accurate to the best of my knowledge.

Signature of Patient (parent or guardian if minor)

Click to Sign

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

Financial Policy

Welcome!
We would like to take this opportunity to extend a personal “Thank you” for allowing us to assist in your oral healthcare needs. Dr. Patel and his staff are trained professionals, who are committed to providing you with the highest quality of surgical care, as your health and well-being are our primary concern. Please understand that prompt payment of expenses is part of your treatment. Thus, the following is a statement of our Financial Policy, which we require you to read and sign before treatment. We are happy to provide you with a signed copy for your records if you would like.

Payment for Services
We accept cash, check, debit cards, Visa, MasterCard, American Express and Discover. We also participate in Care Credit!

Regarding Insurance
We gladly file insurance claims and accept insurance reimbursement on your behalf. However, if you are unable to provide adequate proof of insurance (insurance card or enrollment forms) at the time of your first appointment, payment for your visit is expected at the time of service. Once insurance eligibility and benefits are verified, we will allow you to pay your estimated portion of the treatment and file a claim for the remaining balance. IN THE EVENT OF DENIAL OR NON-COVERED SERVICES, THE PATIENT IS STILL FINANCIALLY RESPONSIBLE FOR ALL SERVICES RENDERED. By law in Georgia, insurance carriers are allowed 15 days to respond to a claim, however as a courtesy to you, we allow 60 days for the claim to be paid. If your insurance carrier does not respond within 60 days, the balance will be transferred to patient responsibility. If left unpaid, there will be a 1.5% monthly interest charge applied monthly to any account balance exceeding 60 days, regardless of insurance status.

Our surgery fees are usual and customary for this area. At times, situations arise in which your insurance carrier may deem your treatment a non-covered service or pay less than the amount billed. Please remember that regardless of your insurance carrier’s arbitrary determination of what charges should be, you are responsible for payment of any unpaid balance. Once the insurance payment is received, and any necessary adjustments are made (this applies to contractual agreements only), you will receive a final statement. Your final account balance is considered payable in full unless other arrangements are made with our Financial Manager. FOR PATIENTS HAVING SECONDARY MEDICAID COVERAGE, YOU MAY STILL BE RESPONSIBLE FOR INSURANCE CO-PAYMENTS AND ANY BALANCE RESULTING FROM NON-COVERED SERVICES, TERMINATED POLICIES OR FAILURE TO PROVIDE ACCURATE INSURANCE INFORMATION AT THE TIME OF SERVICE.

Biopsy/ Laboratory Fees
Many insurance companies have separate deductibles and benefits for surgical procedures and laboratory services. When a biopsy is performed in this office, the specimen or culture is sent to a separate laboratory facility for processing and examination. THE LABORATORY CHARGES ARE SEPARATE FROM OUR FEES. East Georgia Center for Oral & Facial Surgery, LLC. Utilizes Atlanta Oral Pathology, East Georgia Regional Medical Center or Augusta University as our primary reference lab for diagnostic testing. If your insurance carrier requires a specific lab besides these, you must notify the receptionist PRIOR to your appointment. THE PATIENT IS RESPONSIBLE FOR ANY BALANCE RESULTING FROM NON-NETWORK RESTRICTIONS.

Missed/Cancelled Appointments
We understand that unexpected situations sometimes arise, however we do require a 24-hour cancellation notice for appointments. As we allot substantial time in our schedule for surgical procedures, we appreciate proper notice of a need to cancel. Any missed appointments or cancellations without proper notice will be charged a rescheduling fee. Multiple failed appointments may result in dismissal from our care.

We hope the information above has been helpful to you. If you have any questions regarding the above topics or need any additional information, please do not hesitate to speak with one of our team members. We are always happy to help in
any way that we can.

I have read the Financial Policy and I fully understand and consent to the terms of this agreement. I agree to the practices described above as part of my patient care through East Georgia Center for Oral & Facial Surgery, LLC.

Patient's Name

Patient's DOB

Patient’s/ Guardian’s Signature

Click to Sign

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

RELEASE OF INFORMATION

RELEASE OF INFORMATION
(Please check and complete all that apply)

I authorize the release of information including the diagnosis, records, examination rendered to me, claims and billing information.

Yes No

This information may be released to:

Spouse

Yes No

Spouse's Name

Child(ren)

Yes No

Child(ren)'s Name(s)

Other

Yes No

Other Name

Information is not to be released to anyone

The release of information will remain in effect until terminated by me in writing.

truForm by PBHS

Patient Registration & Health History

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Patient Demographics

Please complete the following confidential information:

Insurance Information

Dental Insurance Information

Medical Insurance Information

Person Responsible For Account

Assignment & Release

Click to Sign

Health History

Health History

Are you allergic to, or have you had any adverse reaction to:

Do you have, or have you ever had:

Women Only

Authorization

Click to Sign

Financial Policy

Financial Policy

Click to Sign

Release of Information

RELEASE OF INFORMATION

Messages

Click to Sign

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Patient Registration & Health History

Main Header

Patient Demographics

Please complete the following confidential information:

Insurance Information

Dental Insurance Information

Medical Insurance Information

Person Responsible For Account

Assignment & Release

Click to Sign

Health History

Health History

Are you allergic to, or have you had any adverse reaction to:

Do you have, or have you ever had:

Women Only

Authorization

Click to Sign

Financial Policy

Financial Policy

Click to Sign

Release of Information

RELEASE OF INFORMATION

Messages

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.

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