patient registration - keogh oral surgery · 2018-05-21 · dental plans: access dental (20%...

PATIENT REGISTRATION

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Subscriber: Subscriber: ________________________________________________ ________________________________________________

Today’s Date: Name of General Dentist Referred By Patient Information

Patient’s full legal name: (last, first, middle) Emergency Contact: Phone Number: Has patient been seen here under a different name? yes no If yes, give full name: Date of Birth: / / Social Security Number: / / Street Address: City: State: Zip: Home Phone: Employer/Full Time Student: Gender: Male Female

Person Responsible for Account

Relationship to patient: Gender: □ Male □ Female Full legal name: (last, first, middle) Date of Birth: / / Social Security Number: / / Address (if different from patient): City: State: Zip: Home Phone: Work Phone: Cell Phone: Place of Employment: Employers Address: City: State: Zip: Employment Status: Full Time Part Time Unemployed Occupation:

PRIMARY INSURANCE (DENTAL) PRIMARY INSURANCE (MEDICAL) Subscriber: (Person who carries the coverage) Last Na me First Name

Subscriber: (Person who carries the coverage) Last Name First Name

Address (if different from patient’s): Address (if different from patient’s): City: State: Zip: City: State: Zip: Subscriber SSN & ID#: Birth Date: Subscriber SSN & ID#: Birth Date: Insurance Company: Insurance Company: Address: Address: City: State: Zip: City: State: Zip: Group Name: Group ID#: Group Name: Group ID#:

AURORA14991 E. Hampden Ave., #260Hampden Ave. & Chambers Rd.Aurora, CO 80014PH: 303-699-1964E: [email protected]

PARKER17167 E. Cedar Gulch Pkwy., #100 Jordan Rd. & Main St.Parker, CO 80134PH: 303-699-0351E: [email protected]

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Providing Excellence in Oral & Maxillofacial Surgery Since 1998.

Subscriber: Subscriber: ________________________________________________ ________________________________________________

Subscriber ID#: _______________________ Birth Date: __________




ID#: ________________

ID#: ________________

ID#: ________________

ID#: ________________

IS PATIENT COVERED BY ADDITIONAL INSURANCE? Yes □ No □

SECONDARY INSURANCE (DENTAL) SECONDARY INSURANCE (MEDICAL) Subscriber: (Person who carries the coverage) Last Name First Name

Subscriber: (Person who carries the coverage) Last Name First Name

Address (if different from patient’s): Address (if different from patient’s): City: State: Zip: City: State: Zip: Subscriber SSN & ID#: Birth Date: Subscriber SSN & ID#: Birth Date: Insurance Company: Insurance Company: Address: Address: City: State: Zip: City: State: Zip: Group Name: Group ID#: Group Name: Group ID#:

ASSIGNMENT and RELEASE I, the undersigned certify that I (or my dependent) have insurance coverage with the following Insurance Company(ies): , and assign directly to Aurora Oral & Maxillofacial Surgeons, P.C. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. I understand that interest of 18% per year (1.5% per month) will be charged monthly on outstanding balances of all accounts that are delinquent and that each additional monthly statement will incur a $5.00 billing fee. I understand that I am responsible for any collection cost or attorney fees incurred in collecting a delinquent account as defined above.

Responsible Party Signature Relationship Date

HEALTH HISTORY

Patient’s Name:___________________________________________________________Date:_________________________

Please circle yes or no, whichever applies. Your answers are for our records only and will be confidential.Have there been any changes in your general health in the last year?……………......................……...... Yes / NoWhen was your last physical examination? _______ Physician’s Name:_______________________Phone:________________Are you now under the care of a physician? …………………….……………….…………………………..... Yes / NoIf so, what is the condition being treated? ________________________________________________________________Have you had any serious illness requiring hospitalization? ……………..……….…………………………… Yes / NoIf so please explain:____________________________________________________________________________________Please list past surgical history:__________________________________________________________________________Have you had any serious problems associated with general anesthesia or sedation? …………………..… Yes / NoIf so, please explain:___________________________________________________________________________________ A. Have you had any problems associated with previous dental treatment? .………………………. Yes / No If so, please explain:_________________________________________________________________________ B. Does your jaw joint (TMJ) pop, click, lock, or cause pain? ………………………………………. Yes / NoDo you or have you had any of the following diseases or problems? A. Rheumatic fever or rheumatic heart disease …………...…………………………....…………….. Yes / No B. Heart Murmur ………………………………..………………………………………………………… Yes / No C. Heart valve replacement …………..………………………………………….……………………… Yes / No D. Do you have prosthetic or artificial joints? ……………………………………………..………….…Yes / No E. Cardiovascular disease (heart trouble, heart attack, coronary occlusion, angina, stroke)….…… Yes / No F. High blood pressure or hypertension ………………………………………………….…….........… Yes / No G. Asthma, bronchitis, TB, or emphysema ……………………………………………….…………….. Yes / No H. Fainting spells or seizures ………………………………….………………………………….....….. Yes / No I. Diabetes ………………………………………………………………………………………..……….. Yes / No J. Hepatitis, jaundice, or liver disease ………………………………………………………………..… Yes / No K. Bleeding disorders, prolonged bleeding, difficulty with clotting, or easy bruising………….....… Yes / No L. Sickle cell anemia or sickle cell trait? …………..........……………………………………………… Yes / No M. HIV ……………………………………………………..…………………………………….………... Yes / No N. Arthritis or rheumatism ……………...…………………………………………………..……………. Yes / No O. Stomach ulcers ……………………………………………..………………………………………….. Yes / No P. Kidney trouble …………………………………….…………………………………………...……….. Yes / No Q. Glaucoma ……………………………………….………………………………………….………….. Yes / No R. Do you have any disease, condition, or problems not listed that you think I should know about? Yes / No If so, please explain: ________________________________________________________________________Do you smoke or use other tobacco products? …………………………………………………………...……… Yes / NoAre you currently taking any prescription or over-the-counter medicine? ……………………......…………… Yes / NoPlease list type and dose: __________________________________________________________________________________________________________________________________________________________________________________Are you currently taking any herbal medicines or supplements? ……..…...……...………...……...……..… Yes / NoPlease list type and dose:__________________________________________________________________________________________________________________________________________________________________________________Are you allergic (rash, itching, swelling, difficulty breathing), or have reacted adversely to, any drug or latex? Yes / NoPlease list: ______________________________________________________________________________________________________________________________________________________________________________________________

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Please read and initial the following statements. Sign when completed.

____ 1. Drug or Alcohol Abuse:Do you have a history of social drug or alcohol use? ………….................………………………………. Yes / NoRecreational drug use, overdose with medication, or excessive alcohol consumption can adversely affect the liver function which is critical for producing blood clotting factors. Disclosure will allow your surgeon to safely treat you and prevent excessive post-surgical bleeding that can be life threatening.Current Recreational Drug Use: Interaction with local anesthesia and IV sedation agents can be life threaten-ing. Full disclosure is critical for safe management.

____ 2. IV Sedation / General Anesthesia:I understand that I will not eat or drink for a full eight (8) hours prior to my IV sedation or general anesthetic, not even a drink of water. This is critical to the safety of the procedure. To do otherwise can increase the probability of aspiration and may be LIFE THREATENING!!

WOMEN____ 3. Is there any reason to suspect you may be pregnant? ………………….…………….....………… Yes / NoPregnancy: I understand that if there is a possibility of current pregnancy, I will complete a home pregnancy test prior to scheduling an IV sedation / general anesthetic procedure and report the results to my treating surgeon. Medica-tions used during the surgery and post-operative period can adversely affect the developing baby.

____ 4. Do you have a problem associated with your menstrual cycle? ………...………………….…….. Yes / No

____ 5. Are you on birth control medication? …………………………………………………………….….. Yes / NoBirth Control Pills: Antibiotics are commonly prescribed during your surgical management. Antibiotics can de-crease the efficacy of the birth control pill leading to pregnancy. It is recommended that a second alternative form of birth control be used for one full cycle (month) if pregnancy is not desired.

MEDICAL ALERT____ 6. Are you now or have you ever been treated with oral or intravenous bisphosphonates for Osteoporosis / Osteopenia / Arthritis / Cancer Bone Metastases? ………………………………….…………………….. Yes / NoFailure of disclosure can lead to complications in healing (osteonecrosis of the jaw bone).

Oral Forms: Fosamax, Actonel, Skelid, Didronel, BonivaIntravenous Forms: Zometa, Aredia

The above history is true to the best of my knowledge.

Patient’s Signature: __________________________________________________________ Date:________________

INSURANCEINFORMATIONORAL, MAXILLOFACIAL & IMPLANT SURGEONWe participate with multiple insurance plans for your patient’s convenience.Visit our website at www.keoghoralsurg.com for updated insurance participation.

DENTAL PLANS:Access Dental (20% discount)AetnaAffordable Family Health (25% discount)Alpha Dental (20% discount)Ameriplan (25% discount)AmeritasAnthem BCBS -Specialist, Blue Dental PPO, Blue Dental PPO PlusAscentAssurant (25% discount)Careington (20% discount)Cigna PPOComprehensive Healthcare Option (20% discount)Connection DentalDeCareDelta DentalDental Benefits Providers Inc.Dental Guard / GuardianDental Health AllianceDentemaxDirect Dental Plan (25% discount)Fortis (25% discount)Humana DentalGuardianMedicaid (Limited Services), age 20 and underMetlife PDPNHCD (20% discount)Pacificare Signature SavingsPacificare PPOQCD of America (20% discount)United ConcordiaUnited Dental Care (20% discount)United Health CareWellpoint Dental PPO

MEDICAL PLANS:AetnaCigna PPOCofinityGreat WestHumana Choice PPOMutual of OmahaUnited Healthcare

ORAL & MAXILLOFACIAL SURGERY:Wisdom TeethExtractionsImplantsBiopsyFacial TraumaPre-Prosthetic SurgeryLASER SurgeryTMJ ManagementIV Sedation


ORAL, MAXILLOFACIAL & IMPLANT SURGEONVisit www.keoghoralsurg.com for locations, directions, and for sending referrals or x-rays via email.

Two convenient locations to serve you in the southeast metropolitan area:


AURORA

Hampden

Havana

Chambers

Buckley

Smoky Hill

Parker

Parker

Parker

Iliff

Hampden

Quincy

PonderosaProfessional

Plaza

I-225

Orchard Orchard

ArapahoeArapahoe

Havana

Peoria

Potomac

Jordan

Jordan

E-470

Dry Creek

Centennial Airport

Lincoln

MainRidgegate

Lincoln

Broncos

Cottonwood

E-470County Line

Caley

I-25

I-25

Cherry Creek Reservoir

LONETREE

PARKER

ParkerLocation

CENTENNIAL



NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please read it carefully!

With your consent, the practice is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.

Example of uses of your health information for treatment purposes: A nurse obtains treatment information about you and records it in a health record. During the course of your treatment, the doctor determines a need to consult with another specialist in the area. The doctor will share the information with such specialist and obtain input.

Example of uses of your health information for payment purposes: We submit a request for payment to your health insurance company. The health insurance company requests information from us regarding medical care given. We will provide information to them about you and the care given.

Example of uses of your health information for Health Care Operations: We obtain services from our insurers or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services.

Your Health Information RightsThe health record we maintain and billing records are the physical property of the practice. The information in it, however, belongs to you. You have rights to:

If you want to exercise any of the above rights, please contact the HIPAA Privacy Officer at 303-699-1964 during normal business hours. You may also contact her in person or in writing at 14991 E. Hampden Ave., #260, Aurora, CO 80014. She will provide you with assistance on the steps to take to exercise your rights.

Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office. We are not required to grant the request but we will comply with any request granted;Request that you be allowed to inspect and copy your health record and billing record – you may exercise this right by delivering the request in writing to our office;Appeal a denial of access to your protected health information except in certain circumstances;Request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office;File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information;Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office. An accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing care;Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office; andRevoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office.

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Our ResponsibilitiesThe practice is required to:

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices, and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our Notice or by visiting our office and picking up a copy.

To Request Information or File a ComplaintIf you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact the HIPAA Privacy Officer at 303-699-1964.

Additionally, if you believe your privacy rights have been violated you may file a written complaint at our office by delivering the written complaint to the HIPAA Privacy Officer. You may also file a complaint by mailing or emailing it to the Secretary of Health and Human Services (HHS) whose street address and email address are available upon request.

Other Disclosures and UsesNotification: Unless you object, we may use or disclose your protected health information to notify or assist in notifying a family member, personal representative, or other person responsible for your care, about your location, about your general condition, or your death.

Communication with Family: Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or in payment for such care if you do not object or in an emergency.

Food and Drug Administration (FDA): We may disclose to the FDA your protected health information relating to adverse events with respect to products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.

Workers Compensation: If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

Public Health: As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Abuse and Neglect: We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.

Correctional Institutions: If you are an inmate of a correctional institution, we may disclose to the institution, or its agents, your protected health history necessary for your health and the health and safety of other individuals.

Law Enforcement: We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement.

Health Oversight: Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.

Judicial / Administrative Proceedings: We may disclose your protected health information in the course of any judicial or administrative proceedings as allowed or required by law, with your consent, or as directed by a proper court order.

Other Uses: Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided.

Website: If we maintain a website that provides information about our entity, this Notice will be on the website.

Effective Date: April 14, 2003

I, __________________________________, hereby acknowledge that I have received a copy of this practice’s Notice of Privacy Practices. I have been given the opportunity to ask any questions I may have regarding this Notice.

Patient’s Signature:__________________________________________________________ Date:_____________________

Maintain the privacy of your health information as required by law;Provide you with a notice of our duties and privacy practices as to the information we collect and maintain about you;Abide by the terms of this Notice;Notify you if we cannot accommodate a requested restriction or request; andAccommodate your reasonable requests regarding methods to communicate health information with you.

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We can not and will not require you to waive your right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the practice.We can not and will not retaliate against you for filing a complaint with the Secretary.

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PRESCRIPTION DRUG MONITORING NOTIFICATIONBy signing this form, you confirm that you have been notified that if you receive a prescription for a controlled substance (narcotic drug) from our office and fill that prescription at a pharmacy in Colorado, certain identifying prescription information, including the name of the patient, will be entered into a secure database maintained by Colorado’s prescription drug monitoring program. State law requires pharmacies to report information about controlled substance prescriptions filled to the prescription drug monitoring database.

This database is used to help prevent inappropriate uses of controlled substances – like fraud and diversion. The prescription drug monitoring program database contains only records related to controlled substances (narcotic drugs like painkillers, muscle relaxants and steroids). It does not con-tain records about other prescription drugs like antibiotics, antidepressants or any other category of prescription medication.

Only authorized individuals, like healthcare personnel that prescribe controlled substances and law enforcement (under very limited circumstances), can access the database and only for tightly defined uses. As long as you are using controlled drugs appropriately, there shouldn’t be reason for concern. If you do not want your information in the database, please ask your dentist to prescribe non-narcotic drugs for you.

More information about Colorado’s prescription drug monitoring program, including copies of individual prescription drug records stored in the database, can be obtained from Colorado state Department of Regulatory Agencies by calling 303-894-5957 or by visiting http://www.dora.state.co.us/pharmacy/pdmp/consumers.htm.

I have read and understand this notification.

Name of Patient: _____________________________________________________________

Signature of patient/guardian: _________________________________________________

Date: _______________________________________________________________________

If this notification is signed by a personal representative on behalf of the patient, complete the following:

Personal Representative’s Name: ________________________________________________ Relationship to Patient: _________________________________________________________


REFERRALFORMVisit our website for participating insurance plans and directions.Please email x-rays and referrals to [email protected].



This will introduce

Contact PH# (C) (H) (W)

Please bring current dental and medical insurance cards, this referral form and x-rays to your appointment.

Notes:

Date Referring Doctor PH#


(patients name)

❏ Preprosthetic Surgery ❏ Pathology: Site ❏ Grafting/Augmentation ❏ TMJ Management

RIGHT

A B C D E F G H I J

T S R Q P O N M L K

LEFT

❏ Exodontia ❏ Implants

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

24 23 22 21 20 19 18 1732 31 30 29 28 27 26 25

MAP


AURORA

Hampden

Havana

Chambers

Buckley

Smoky Hill

Parker

Parker

Parker

Iliff

Hampden

Quincy

PonderosaProfessional

Plaza

I-225

Orchard Orchard

ArapahoeArapahoe

Havana

Peoria

Potomac

Jordan

Jordan

E-470

Dry Creek

Centennial Airport

Lincoln

MainRidgegate

Lincoln

Broncos

Cottonwood

E-470County Line

Caley

I-25

I-25

Cherry Creek Reservoir

LONETREE

PARKER

ParkerLocation

CENTENNIAL

patient registration - keogh oral surgery · 2018-05-21 · dental plans: access dental (20%...

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