309 2nd St
Auburn, WA 98002
Phone: (253) 929-8711
T, W: 9:00AM-5:00PM
2345 SW 320th St
Federal Way, WA 98023
Phone: (253) 838-2123
M, W: 9:00AM-5:00PM
601 South Carr Rd
Renton, WA 98055
Phone: (425) 277-1844
M, T: 9:00AM-5:00PM
26808 Maple Valley Black Diamond Rd SE
Maple Valley, WA 98038
Phone: (425) 432-1511
8012 112th St CT E, Suite 260
Puyallup, WA 98373
Phone: (253) 770-1000
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How do you prefer to be contacted?
If you prefer to be contacted by cell phone, may we leave automated messages on your voicemail?
My signature confirms that I have been informed that I have the rights to privacy regarding my protected health information, and I have been given the opportunity to review this office's Notice of Privacy Practices as required by the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to:
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Relationship to Patient
May we discuss your personal information with your emergency contact?
If YES, you must list this person below.
I give permission to discuss my medical and/or financial information with:
I grant my permission for PNWOMS to use photographs or digital images taken during my visits for promotional and/or educational purposes
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Payment (select one)
INFORMATION RELEASE: I authorize the release of any information requested by my insurance company regarding treatment.
NOTE: This office will not release information regarding your care or furnish copies of your record to anyone without your signed permission.
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We appreciate your confidence in allowing us to provide care. Correct answers to the following questions will allow us to provide care appropriate to your needs. This information is confidential. Any omissions or incorrect information could compromise care and lead to serious complications. If you have any questions, please ask for clarification.
Have you ever taken a biophosphonate drug?
Do you wear contact lenses?
Have you ever been given general anesthesia?
Do you or a family member have a history of or have you been diagnosed with malignant hyperthermia?
Do you have any other medical disease, condition, or problem not listed above that you think the doctor should know about?
Do you have pain management contract with your physician?
Have you had or do you curretly have:
Are you pregnant?
Are you using birth control medication?
I understand the importance of providing a truthful history to assist my doctor in providing the best care possible. The information I have provided here is complete and accurate.
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Please fill out this section even if you are the person financially responsible!
Are you 18 years or older?
If yes, please note that you are financially responsible for yourself. If your parent or guardian is financially responsible for you, they will need to be present at your examination/consultation appointment and will need to sign all necessary paperwork.
Person financially responsible for account:
When you are in the midst of being treated for a medical or dental problem, it's easy to forget that a doctor's office is also a business. We understand that. Yet we also want our patients to understand an important part of any business is also collecting payments for the services it provides. In the interest of both good medicine and good business, we believe it's best to establish a policy to avoid misunderstandings later. As a result, we have developed this billing policy.
I request and authorize Pacific Northwest Oral & Maxillofacial Surgery to provide me with medical or dental services. I understand that I am personally responsible for the charges incurred for the services I receive. I agree to make full payment for services I receive unless prior arrangements have been made in writing.
I agree to pay all reasonable attorney fees and cost of collection incurred by PNWOMS if my account is not paid as agreed. I also agree to pay interest on my unpaid balance at the rate of 12% per annum commencing 90 days after the date of service.
As a patient (or guardian of a patient), I understand that this office does not acknowledge agreements between parents accepting or denying financial responsibility for the services provided. We consider the guardian (custodial) parent to be responsible for payment of services received.
I hereby authorize PNWOMS, at discretion, to bill my insurance carrier and any other person or parties who may be liable for payment of these services. I also authorize my insurance carrier to make payment directly to PNWOMS.