Section 1 of 6 in this document

PATIENT INFORMATION

Gender

Marital Status

Section 2 of 6 in this document

WHO WILL BE RESPONSIBLE FOR YOUR ACCOUNT?

(If self, skip to next section)

Who will be responsible for the account?

SPOUSE OR OTHER GUARANTOR INFORMATION

Section 3 of 6 in this document

MEDICAL HISTORY

Have you had any serious illnesses?

Are you under the care of a physician at present?

Are you taking any medications now, or have you in the past year?

Have you ever been hospitalized for any overnight stays?

Have you or has anyone in your family had a problem with anesthesia?

Do you have any allergies?

Have you ever had a blood transfusion?

Are you pregnant?

Do you presently wear contact lenses?

Do you drink alcohol?

Do you smoke?

Have you ever had any of the following?

Are you presently taking, or have you ever taken any of these drugs?

Section 4 of 6 in this document

INSURANCE INFORMATION

Is the patient a child (dependent)?

If yes, are the parents divorced?

Is the patient a student?

If yes

Primary Medical Insurance Company

Gender

Secondary Medical Insurance Company

Gender

Primary Dental Insurance Company

Gender

Secondary Dental Insurance Company

Gender

I authorize the release of any medical/dental or other information necessary to process this claim. I also request payment of benefits to Huntsville Oral Surgery & Dental Implants.

Section 5 of 6 in this document

EXPLANATION OF INSURANCE PRACTICE POLICY AND RELEASE OF INFORMATION & BENEFIT ASSIGNMENT

We will prepare any necessary forms to collect payment from your insurance company and will credit such collections to your account. However, we cannot render services on the assumption that charges will be paid by your insurance company.

Most misunderstandings about insurance can be avoided if you understand what your policy provides.

Any estimate of benefits we provide to you are rendered based upon what you and/or your carrier have represented to us, and if your carrier does not pay for any reason whatsoever, you are responsible for payment. Further, if your insurance coverage or policy changes prior to your surgery, it is your responsibility to notify our office so that we may re-process your benefit estimate. If we do not receive payment from your insurance company within sixty (60) days of surgery, you are responsible for payment in full, and you agree to look to your carrier for reimbursement.

I have read and understand the foregoing “Explanation of Insurance Practice Policy and Release of Information & Benefit Assignment.” I hereby unconditionally guarantee payment for medical and dental services rendered to the above-named patient; this is to include any and all future services, as well as those presently contemplated. I hereby authorize payment of all medical and dental charges incurred by me or my dependents for services rendered by Huntsville Oral Surgery & Dental Implants are my financial responsibility. I agree to pay attorney’s fees in the event such services are placed in the hands of an attorney for collection. The guaranty shall continue in effect until revoked in writing by me and until such written revocation is delivered to Huntsville Oral Surgery & Dental Implants.

Insured’s or Authorized Person’s Signature

I authorize the release of any medical/dental or other information necessary to process the claim. I also request payments of benefits to Huntsville Oral Surgery & Dental Implants for services rendered.

HIPPA AUTHORIZATION FORM

HIPAA (Health Insurance Privacy & Accountability Act) does allow us to release information to outside entities on your behalf. Example: Another medical/dental office, your insurance company, your pharmacy, or hospital.

I authorize the release of information, including but not limited to: diagnosis, records, appointment time, examination rendered to me, and claims information.

This information may be released to the following (please list individuals by first and last name):

The Notice of Privacy Practices for Huntsville Oral Surgery & Dental Implants has been made available to me. This Release of Information will remain in effect until terminated by me in writing.