Patient Information Forms

"*" indicates required fields

Step 1 of 4

1. New Patient Information

Name*

First Last

Address*

Street Address City State ZIP Code

Date of Birth*

Gender*

Social Security #*

Other:*

Marital Status*

Home/ Cell Phone Number

Email Address

May We Text You?*

May We Email You?*

Drivers license or if minor, drivers license of financial party

Max. file size: 50 MB.

Referring Dentist / Doctor

Practice Name

Who is Your Medical Doctor?

Practice Name

Do You Have Medical or Dental Insurance?*

Is this PRIMARY Insurance?*

Insurance Company Name*

Insurance Claims Billing Address & Phone Number (usually on the back of the card)*

Policy Holder’s Relationship to Patient (self, spouse, child, etc...)

Subscriber Name*

Subscriber/Policy Holder ID #*

Group ID #*

Policy Holder’s Employer (if applicable)

Policy Holder’s Date of Birth*

Policy Holder’s Social Security #*

Policy Holder’s Phone Number

Policy Holder’s Email Address*

Front Image of Insurance Card*

Max. file size: 50 MB.

Back Image of Insurance Card*

Max. file size: 50 MB.

Do You Have Other Medical or Dental Insurance?*

Insurance Company Name?*

Subscriber Name*

Insurance Claims Billing Address & Phone Number (usually on the back of the card)*

Policy Holder’s Relationship to Patient (Self, Spouse, Child, etc...)*

Subscriber / Policy Holder ID #*

Group ID #*

Policy Holder’s Employer*

Policy Holder’s Date of Birth*

Policy Holder’s Social Security #*

Policy Holder’s Phone Number

Policy Holder’s Email Address

Front of Insurance Card

Max. file size: 50 MB.

Back of Insurance Card

Max. file size: 50 MB.

**If MINOR (UNDER 18) or a guardian/parent is financially responsible for your account, please fill out the following information:

Father / Mother / Guardian Name

Date of Birth*

Driver’s License Number

Social Security #

Private Information may be Discussed With?

Name

Relationship

Their Phone Number

I authorize the Doctor/Staff to perform oral surgery and/or examination for the purpose of treatment. I also authorize the taking of x-rays required as a necessary part of this examination. Additionally, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment. Furthermore, 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.

Signature of patient or legal guardian*

3. Financial Agreement

Thank you for choosing us as your surgery provider. We are committed to providing you with the highest quality care at an affordable rate. Recently, our patients’ families have had questions regarding what is their financial responsibility and/or the insurance’s responsibility for services rendered. Please read this policy, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request.

1. Insurance

We are OUT-OF-NETWORK with most insurance companies. It is your responsibility to determine if we are IN-NETWORK with your plan. As a courtesy to you, we will bill your primary insurance. However, the responsibility for payment remains with the patient (or guarantor). If you have additional coverage, we will assist you in billing your secondary policy so long as the information is provided. Knowing your individual insurance plan benefits & frequency limitations is your responsibility.

We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may contact you directly if any additional information is necessary to process a submitted claim. It is your responsibility to comply with their request in a timely fashion. Please be aware that the balance of your claim is your responsibility whether your insurance company pays your claim or not. If your insurance does not pay your claim in 45 days, the balance will automatically be billed to you. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.

Retroactive Insurance Termination & Insurance Refunds: In the event that my insurance company retroactively terminates my policy or requests a refund of payment from the office for any reason, I understand that I will be responsible for all unpaid balances on my account. I understand that insurance requests for refunds due to retroactive termination & other reasons can occur at any time and in some cases up to 12 months past the date of service. Full standard fees will apply (not in-network insurance contracted rates) in the event of a terminated or inactive policy.

2. Treatment Estimates

As a courtesy to you, we can provide a “TREATMENT ESTIMATE” but it is simply an estimate. Many insurance plans state you will be covered up to “50%, 80%, or 100%”. However, we have found that many plans cover less than that depending upon their established “usual and customary” fees, not our actual fees. To determine exactly what portion of your bill will be covered by insurance, we will gladly request predetermination from your insurance carrier, however, this usually requires four to six weeks to be processed.

3. Co-payments & Deductibles

All ESTIMATED co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and/or deductibles from patients can be considered insurance fraud. Please help us in upholding the law by paying your co-payment and/or deductible at each appointment.

4. Non-covered Services

Please be aware that some - perhaps all - of the services you receive may be non-covered or not considered reasonable or necessary by your insurance policy (including but not limited to Medicaid/DKC). By signing a treatment plan authorizing the work to be completed, you are accepting financial responsibility for those services.

5. Proof of Insurance

All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver’s license and current/valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information at each appointment, you will be responsible for the balance of the claim.

6. Coverage Changes

If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits.

7. Nonpayment

If your account is over 90 days past due, you will receive a letter stating that you have 10 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency, Tek Collect. If this occurs, you will be notified by certified mail that you have 30 days to find alternative care. During that 30 day period, our doctor will only be able to treat you on an emergency basis.

Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area. Thank you for understanding our insurance billing and payment policy. Please let us know if you have any questions or concerns.

Name*

First Last

Signature*

Contact Info

Contact Us

Patient Information Forms

1. New Patient Information

2. New Patient Health History and Information

14. Do you have a history of any of the following? (Please check yes or no – do not leave any blank.)

3. Financial Agreement

4. HIPAA Release

Patient Privacy Practices Acknowledgement

Please Leave Blank: For Office Use Only

LOCATION

All Alaska Oral & Craniofacial Surgery

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