Degen DDS - New Patient Info

Thank you for choosing Red Rock Oral & Maxillofacial Surgery Centre

Please complete the following form before visiting our office. Contact our office if you have any questions.
Patient Information
Patient Name*

First NameLast Name
Birth Date*

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please Include a Picture of Your Driver's License (front)

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Email Address
example@example.com
Phone - Mobile
Phone - Work
Phone - Home
SS#
Gender

MaleFemale
Emergency Contact

First NameLast Name
Emergency Phone
Dental Insurance
Is the Patient also the Policy Holder?

YesNo
Policy Holder Name

First NameLast Name
Policy Holder DOB

MonthDayYear
Policy Holder SS#
Policy Holder Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Holder Relation to Patient
Policy Holder Employer - Company
Insurance Company Name
Insurance Policy ID#
Insurance Group ID#
Please Include a Picture (front and back) of Insurance Card

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Do You Have Secondary Insurance?

YesNo
Is the Secondary Insurance by the Same Policy Holder?

YesNo
Secondary Policy Holder Name

First NameLast Name
Secondary Policy Holder DOB

MonthDayYear
Secondary Policy Holder Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Policy Holder Relation to Patient
Secondary Policy Holder Employer - Company
Secondary Policy Holder Insurance Company
Secondary Policy Holder Policy ID#
Secondary Policy Holder Group ID#
Please Include a Picture (front & back) of Insurance Card

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Consent For Disclosure of Information
I give permission to this office to leave detailed messages on the following:*

Mobile PhoneHome PhoneWork PhoneNone of the above
The physicians at Red Rock Oral and Maxillofacial Surgery Centre are committed to complying with HIPAA regulations. Therefore, we require our patients to sign authorization stating those individual(s) (family members, friends, etc.) that are approved to hear discussion and obtain patient health information.
Authorized Individuals
Financial Policy

Please review our financial policies carefully.
Our office will file insurance claims for you as a courtesy. If there are services your insurance plan does not cover, you will be responsible for the unpaid balance. All charges are your responsibility whether your insurance company pays or not. You must provide us with the correct billing information regarding your insurance and inform us of any changes immediately. You are responsible for knowing the policies of your insurance plan(s), including co-pays, deductibles and when prior authorization is required for tests or surgery. Every insurance policy is different and knowing what your insurance covers or disallows will aid in making your visit here a positive experience.
All payments are due at the time services are rendered. You will not be charged for immediate post-operative care. Additional charges will be applied to your account for any x-ray's required during post-operative care. We will assist you in obtaining authorization and pre-estimates for any proposed surgery. If you have not received a call from us within 2-3 week period, please contact our office and we will call your insurance to check the status. If you decide not to wait for the insurance pre-determination to return, you will be required to pay any additional fees up front which will apply towards your account balance. Any outstanding balance that has not been paid by 90 days from the date of service will accrue a finance charge of two (2%) per month interest, twenty four (24%) per year. A collection notification will be sent to delinquent accounts after 90 days from the last day which treatment was rendered. Please contact us if you feel a refund is required. Refunds are returned once per month. We are here to assist you in any way possible. Please make your questions and concerns known to our team. Our goal is to ensure that you have an outstanding experience. If for any reason you cannot keep a surgical appointment, you must call our office and speak with an office employee at least 48 hours in advance of your scheduled appointment, otherwise you will be charged $50.00.
Assignment Of Benefits And Release Of Information

I authorize Mark I. Degen, D.D.S., M.D., Ltd. dba Red Rock Oral & Maxillofacial Surgery Centre and associated staff to bill my insurance directly for any services rendered. I understand that I am financially responsible for all charges not paid by my insurance company including co-pays, deductibles, and any other charges that my insurance company denies. I agree to pay these charges at the time of service. I authorize Dr. Mark Degen and associated staff to furnish necessary information from my confidential medical record to the following: physicians requesting information for consultation, patient's health insurance carriers for reimbursement of fees and/or any third party which may be liable for all or part of the patient's physician fee.
I understand and agree that (regardless of my insurance status), I am ultimately responsible for the balance of my account for any professional services rendered. I have read all the information on this sheet and have completed the above answers. I certify that this information is true and correct to the best of my knowledge. I will notify the office of any changes in my status or the above information.
Signature of Patient or Legal Guardian*

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Date*

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Date
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Thank you for choosing Red Rock Oral & Maxillofacial Surgery Centre

Patient Information

Dental Insurance

Consent For Disclosure of Information

Financial Policy