Please add contact information for a relative who lives close to you, but not in your home:

Please list any medications you are currently taking, including dosage and frequency:

I certify that I have read and I 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 his/her staff, responsible for any errors or omissions that I have made in the completion of this form.

We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance, we will be glad to fill out the proper forms, but please complete the identifying information on this form.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorney's fees, and court costs.

I authorize my surgeon and his/her designated staff to perform an oral and maxillofacial examination for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all X-rays required as a necessary part of this examination. In addition, if medically necessary, I authortize the release of any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers. I permit messages to be left on my phone and/or mobile phone concerning my appointment.

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.

This notice describes how health information about you may be used and disclosed an how you can get access to this information. Please review it carefully. The privacy of your health information is important to us.

Federal and state law requires us to maintain the privacy of your health information. That law also requires us to give you this notice
about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices we describe in this notice while it is in effect. This notice takes effect April 14, 2003, and will remain in effect until we replace it. 

We reserve the right to change our privacy practices and the terms of this notice at any time, provided such applicable law permits the changes. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and make the new notice available upon request. 

You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information at the top of this notice.

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

TREATMENT:
We may use your health information for treatment or disclose it to a dentist, physician, or other healthcare provider providing treatment to you.

PAYMENT:
We may use and disclose your health information to obtain payment for services we provide to you. We may also disclose your health information to another healthcare provider or entity that is subject to the Federal Privacy Rules for its payment activities.

HEALTHCARE OPERATIONS:
We may use and disclose your health information for our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, and certification, licensing, or credentialing activities. We may disclose your health information to another healthcare provider or organization that is subject to the federal privacy rules and that has a relationship with you to support some of their healthcare operations. We may disclose your information to help these organizations conduct quality assessment and improvement activities, review the competence or qualifications of healthcare professionals, or detect or prevent healthcare fraud and abuse.

ON YOUR AUTHORIZATION:
You may give us written authorization to use your health information or to disclose it to anyone. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any uses or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this notice.

TO YOUR FRIENDS AND FAMILY:
We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your health care or with payment for your health care. Before we disclose your health information to these people, we will provide you with an opportunity to object to our use or disclosure. If you are not present, or in the event of your incapacity or an emergency, we will disclose your medical information based on our professional judgment of whether the disclosure would be in your best interest. We may use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, X-rays, or other similar forms of health information. We may use or disclose information about you to notify or assist in notifying a person involved in your care, of your location, and general condition.

APPOINTMENT REMINDERS OR OTHER INFORMATION: 
We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

DISASTER RELIEF:
We may use or disclose your health information to a public or private entity authorized by law or by its charter to assist in disaster relief efforts.

PUBLIC BENEFIT:
We may use or disclose your medical information as authorized by law for the following purposes deemed to be in the public interest or benefit:

• As required by law
• For public health activities, including disease and vital statistic reporting, child abuse reporting, FDA oversight, and to employers regarding work-related illness or injury
• To report adult abuse, neglect, or domestic violence
• To health oversight agencies
• In response to court and administrative orders and other lawful processes
• To law enforcement officials pursuant to subpoenas and other lawful processes, concerning crime victims, suspicious deaths, crimes on our premises, reporting crimes in emergencies, and for purposes of identifying or locating a suspect or other person
• To coroners, medical examiners, and funeral directors
• To an organ procurement organization
• To avert a serious threat to health or safety
• In connection with certain research activities
• To the military and to federal officials for lawful intelligence, counterintelligence, and national security activities
• To correctional institutions regarding inmates
• As authorized by state workers’ compensation laws

ACCESS:
You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You may request access by sending us a letter to the address at the end of this notice. If you request copies, we will charge you a reasonable cost-based fee that may include labor, copying costs, and postage. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we may — but are not required to — prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this notice for more information about fees.

DISCLOSURE ACCOUNTING:
You have the right to receive a list of instances in which our business associates or we disclosed your health information over the last six years (but not before April 14, 2003). That list will not include disclosures for treatment, payment, healthcare operations, as authorized by you, and other activities. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Contact us using the information listed at the end of this notice for more information about fees.

RESTRICTION:
You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Any agreement we may make to a request for additional restrictions must be in writing signed by a person authorized to make such an agreement on our behalf. Your request is not binding unless our agreement is in writing.

ALTERNATIVE COMMUNICATION: 
You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. You must make your request in writing. You must specify in your request the alternative means or location and provide satisfactory explanation how you will handle payment under the alternative means or location you request.

AMENDMENT: 
You have the right to request that we amend your health information. Your request must be in writing, and it must explain why we should amend the information. We may deny your request under certain circumstances.

If you want more information about our privacy practices or have questions or concerns, please contact our office.

If you believe any of the following, you may contact our office.

• We may have violated your privacy rights.
• We made a decision about access to your health information incorrectly.
• Our response to a request you made to amend or restrict the use or disclosure of your health information was incorrect, or we should communicate with you by alternative means or alternative locations.

You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Thank you for choosing North Jersey Oral & Maxillofacial Surgery as your healthcare provider. We are committed to your treatment being successful. The following is a statement of our Financial Policy, which we require you to read and sign prior to any treatment. All patients must complete our Information and Insurance Form before seeing the doctors.

PAYMENT IS DUE AT TIME OF SERVICE.
WE ACCEPT ALL MAJOR CREDIT CARDS, CHECKS, AND CASH.
WE ALSO OFFER CARECREDIT^®. 

REGARDING INSURANCE
The balance of your account is your responsibility, whether your insurance company pays or not. We cannot bill your insurance company unless you provide us with complete and accurate insurance information. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. In the event that we do not accept assignment of benefits, we require that you make prior arrangements for payment. Please be aware that some, and perhaps all, of the services provided may be non-covered services and not considered reasonable and necessary under the Medicare Program and/or other medical or dental insurances.

USUAL AND CUSTOMARY RATES
Our practice is committed to providing the best treatment for our patients, and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates. 

All patients are responsible for full payment at the time of services. The adult accompanying a minor is responsible
for full payment. If payment is not received and collection proceeding occurs, you will be responsible for the 35%
collection fee as well as any court costs and all attorney and legal fees incurred.

Thank you for understanding our Financial Policy. Please let us know if you have questions or concerns. 

I have read the Financial Policy; I understand and agree to this Financial Policy.