Patient Registration Forms

Your Privacy Is Protected

This form should only take 5-10 mins.

This form is HIPAA-compliant and meets all requirements for the secure handling of your personal health information. To protect your privacy:

• End-to-end encryption ensures that your responses are securely transmitted.
• Only authorized personnel will have access to your submissions.
• We do not share or sell your information to third parties. 

By completing this form, you can feel confident that your information is handled with the highest level of privacy and care in accordance with federal HIPAA standards.

*PLEASE NOTE - omission of necessary health information, i.e., the use of ilicit drugs, any marijuana products and non FDA approved herbal supplements; can endanger your life during surgery and lead to lethal complications.  This is a "no judgement zone", please be as forthcoming as possible.  We truly love all of our patients and want only the best for you!

**Just like any hospital or healthcare facility, Social Security Numbers are required to verify your insurance coverage / savings.  Without this critical piece of information, we will not be able to provide you and your family members with any estimates for your consultation and/or upcoming surgeries.

To our patients: Although oral surgeons primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have, or medications that you may be taking, could have an important interrelationship with the care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

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 doctor, or any other member of the staff, liable for any errors or omissions that I have made in the completion of this form.

FEES & PAYMENTS

We make every effort to keep down the cost of your care.  On special circumstances, other 3rd party arrangements, i.e., Cherry, Carecredit, can be made with our office PRIOR to the day of surgery.  Any estimated charges for your treatment is due PRIOR to any treatment. If you have any insurance coverage / savings, we will assist you in submitting the proper forms so you can get reimbursed.

Most insurance companies have a fixed ANNUAL allowance for dental procedures, about $1500 - 3000 / year.  This will only cover a percentage of the charge.  The remaining balance is considered your out-of-pocket or your "co-pay. You are required to pay this PRIOR to any treatment.  Any remaining balance not paid for by your insurance company is the "patient's responsibility".  If we are unable to collect the amount due in 90 days after the treatment, the account will be send to collections and you will be responsible for any associated cost of collections.

INSURANCE PAYMENT AUTHORIZATION

This signature on file is my authorization for the release of any information necessary to process my insurance claim. I hereby authorize payment to the doctor named of the benefits otherwise payable to me.

AUTHORIZATION

I authorize my doctor to perform the necessary examination, for the purpose of diagnosis and treatment planning.

Furthermore, I authorize the taking of all X–rays / 3D CBCT 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, dentists and/or insurance carriers.

NOTICE OF PRIVACY PRACTICES

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. (click here to see our Notice of Privacy Practices HIPAA form)