New Patient Packet

1Patient Information

2Parent's/Guardian

3Emergency/Referral contacts

4Insurance Information

5Financial Policy

6Health History

7Health History (Contd.)

Status(Required)

Patient's Name(Required)

First Name Middle Initial Last Name

SS#(Required)

Date of Birth(Required)

Age(Required)

Gender(Required)

Male

Female

Address(Required)

Street Address Apt City State ZIP

Home Phone(Required)

Cell Phone(Required)

Email(Required)

Full Time Student?

Yes

Employer

Name of parent or legal guardian accompanying minor

Parent's/Guartian's Name

First Name Last Name

Date of Birth

SS#

DL#

State

Address

Same as Patient's Address

Street Address Apt City State ZIP

Relationship to Minor

Home Phone

Cell Phone

For children under 18 years of age, the legal guardian or parent accompanying the child to this appointment is deemed the responsible party for the payment on this account.

Emergency Contact

Phone

Relationship

Acceptance(Required)

I authorize the doctors or staff to discuss my care and/or treatment with my primary emergency contact or person listed above.

initialization Initials(Required)

(Initial)

Referred by

First Name Last Name

Patient's Dentist

First Name Last Name

Do You Want to Enter Insurance Information?(Required)

Yes

DISCLAIMER: Arizona Center for Oral Surgery is not a contracted provider with the Arizona Health Care Cost Containment System (AHCCCS). Arizona state law prohibits us from providing services to individuals who are enrolled in AHCCCS, regardless of any other insurance coverage they may have or their willingness to pay out-of-pocket.

Disclaimer Acceptance(Required)

* By checking this box, I confirm that I DO NOT have AHCCCS health insurance. I understand and agree to the terms stated above regarding AHCCCS coverage and treatment at this office.

Primary Dental Insurance

Insurance Company

Insurance Phone

Insured

First Name Last Name

SS/ID#

DOB

Insured Address

Same as Patient's Address

Street Address Apt City State ZIP

Employer

Group#

Relationship to Patient

Secondary Dental Insurance

Insurance Company

Insurance Phone

Insured

First NAme Last Name

SS/ID#

DOB

Insured Address

Same as Patient's Address

Street Address Apt City State ZIP

Employer

Group#

Relationship to Patient

Signature

Date

FINANCIAL POLICY AND PRACTICE NOTICES

Privacy Practice Acknowledgement for All Patients

Acknowledgement Initials(Required)

Please Initial

HIPAA Notice: You have the right to read our Notice of Privacy Practices before you decide to initial this section. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices to follow federal/state guidelines. You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to our office. Please understand that revocation of this Consent will NOT affect any action we took in reliance on this consent before we received your revocation and that we may decline to treat you or to continue treating you if you revoke this consent.

Financial Agreement

Financial Agreement Initials 1(Required)

Please Initial

I understand payment (including co-payment if billing insurance for covered procedure) is due at the time services are rendered. Cash, Debit, Credit Cards (subject to 1.5% processing fee) Money Order, Care Credit, and Checks are accepted methods of payment.

Financial Agreement Initials 2(Required)

Please Initial

I understand that upon failure to pay for services rendered, my account (including all personal information) may be sent to a collection agency. An additional collection agency fee of 30% will be applied to the account’s outstanding balance.

For Patients with Insurance Only

For Patients with Insurance Only Initials 1(Required)

Please Initial

ASSIGNMENT AND RELEASE: I hereby authorize payment to Arizona Center for Implant, Facial and Oral Surgery for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents. I authorize the use of this signature on all insurance submissions. I further authorize the doctor to initiate a complaint to the Insurance Commissioner for any reason my behalf, should the need arise.

For Patients with Insurance Only Initials 2(Required)

Please Initial

If there is insurance, the balance is due within 60 days from the date of service or when insurance pays, whichever is first. Pursuant to the Federal Consumer Credit Protection Act, we disclose that no interest charge will be applied if this agreement is adhered to. If the terms of this agreement are not met, interest charges of 1.5% per month is to be adhered to the remaining balance (18% per year) in addition to the entire balance becoming due.

For Medicare Beneficiaries Only

For Medicare Beneficiaries Only Initials

Please Initial

I have reviewed agree to the terms of the Private Contract (dated 7/2014) and understand Medicare will not be billed for any services rendered.

Signature

Date

Name of parent or legal guardian accompanying minor

Primary Dental Insurance

Secondary Dental Insurance

Privacy Practice Acknowledgement for All Patients

Financial Agreement

For Patients with Insurance Only

For Medicare Beneficiaries Only

Answer all questions by circling Yes or No

7. Do you have or have ever had any of the following?

8. Are You Using Any of the Following?

9. Are You Allergic to or Have You Had an Adverse Reaction to