New Patient Form

New Patient Form

Ivey Oral & Facial Surgery
Are you a Medicaid Patient?*

YesNo
Our office does not accept Medicaid – Please call us directly at (303) 493-1933 for further instructions, and review this link for Colorado state laws relating to Medicaid: CLICK HERE
Personal Information
Date*

MonthDayYear
Legal Full Name*

First NameMiddle NameLast Name
Preferred Name
Date of Birth*

MonthDayYear
Sex Assigned at Birth*

MaleFemale
Pronouns*
Calculated Age
*** MINOR PATIENTS MUST BE ACCOMPANIED BY A PARENT/GUARDIAN ***
If other pronoun, please specify:*
Social Security Number
Marital Status*

SingleMarriedDivorcedWidow
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Home Number
Please enter a valid phone number.
Cell Number
Please enter a valid phone number.
Email*
example@example.com
General Dentist Name
If Full-time student, School Name
Grade

Insurance Information

Ivey Oral & Facial Surgery
MINOR CHILD - May need to complete both Primary and Secondary Insurance fields for parent information.
ADULTS - Complete Primary Insured
DUAL COVERAGE - Also complete both Primary and Secondary Insurance fields.
Self Pay*

YesNo
MEDICARE*

YesNo
MEDICAID*

YesNo
Primary Insured

(If no insurance, complete for responsible)
Primary Insured Name

First NameMiddle NameLast Name
Primary Insured Address

Street Address

Street Address Line 2

CityState

Zip Code
Primary Insured Home Phone Number
Please enter a valid phone number.
Primary Insured Work Phone Number
Please enter a valid phone number.
Primary Insured Cell Phone Number
Please enter a valid phone number.
Primary Insured Email
example@example.com
Primary Insured Date Of Birth

MonthDayYear
Date
Relationship to Patient
Employer
Dental Insurance Company Name
Subscriber Number
Group Number
Primary Insured Social Security Number
Do you have a Secondary Insurance?*

YesNo
Secondary Insured
Secondary Insured Name

First NameMiddle NameLast Name
Secondary Insured Address

Street Address

Street Address Line 2

CityState

Zip Code
Secondary Insured Home Phone Number
Please enter a valid phone number.
Secondary Insured Work Phone Number
Please enter a valid phone number.
Secondary Insured Cell Phone Number
Please enter a valid phone number.
Secondary Insured Email
example@example.com
Secondary Insured Date Of Birth

MonthDayYear
Date
Relationship to Patient
Employer
Dental Insurance Company Name
Subscriber Number
Group Number
Secondary Insured Social Security Number

Emergency and Pharmacy Information

Ivey Oral & Facial Surgery
Person to Contact In Case of Emergency
Emergency Contact Name*

First NameLast Name
Emergency Contact Address*

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact Phone Number*
Please enter a valid phone number.
Who may we thank for referring you to our office:*
Has any member of your family ever been treated in our office?

YesNo
Pharmacy Information
Pharmacy Name*
Pharmacy Phone Number
Please enter a valid phone number.
Pharmacy Location*

Patient Acknowledgement

Ivey Oral & Facial Surgery
Date Today

MonthDayYear
Date
I understand the importance of accurate, truthful health history to assist the doctor in providing the best care possible. I have had the opportunity to discuss my health history with the doctor.
Signature of Patient or Representative (please hold down mouse button and sign)*

Clear

Financial Policy

Ivey Oral & Facial Surgery
Welcome to our office! At Ivey Oral & Facial Surgery, we are proud to be a team of healthcare professionals whose goal is to provide you with the highest quality and most cost-effective care possible. We are aware that unexpected healthcare costs can significantly impact your budget ad we want to make our services as affordable as possible. In order to assist you with your healthcare investment, we ask that you read the following information regarding our available payment options. The patient (or parent/legal guardian, if the patient is a minor) is responsible for payments in full at the time our services are rendered.

INSURANCE

We will gladly estimate your deductible, your portion of treatment costs, and bill your insurance company for your treatment fees, all at no extra cost to you. The estimated amount not covered by your insurance company is due at the time the treatment is rendered. Our estimates are subject to final approval by your insurance company; therefore, YOUR EXACT PORTION OF THE TREATMENT COSTS CANNOT BE DETERMINED UNTIL WE HAVE RECEIVED THE FINAL PAYMENT FROM YOUR INSURANCE COMPANY. If you have a balance remaining after insurance pays, you will be sent a final statement at that time. We do not bill secondary insurance companies, but we will provide you with copies of the needed information so that you can forward them to your secondary insurance company for reimbursement.

Please remember that your insurance is your responsibility. While we are happy to help you with claims submission, we can make no guarantee about your insurance payment. We allow 45 days for your insurance company to make payment. After this time all inquiries and follow-ups become your responsibility. No finance charges will be applied if all balances are paid in full within 90 days of date of service.
PRE-AUTHORIZATION OF INSURANCE BENEFITS

Pre-authorization of insurance benefits may be in your best interest. Many patients are uncertain if recommended treatment is covered by their insurance plan, or what percentage the insurance may pay for covered benefits. In some cases, insurance companies do require pre-authorization for any treatment that will be over a specific dollar amount or certain types of treatment. In these situations, we will be happy to send the required information to your insurance company for pre-authorization consideration. This process normally takes 3 to 6 weeks for insurance companies to process the paperwork and get it back to us. Emergency treatment is normally excluded from this pre-authorization process.

PAYMENT INFORMATION

Payment options: Financial options are discussed during the initial visit. Ivey Oral & Facial Surgery are committed to providing excellent care and guiding patients in selecting the best payment option for their individual needs. We accept CASH, PERSONAL CHECK, VISA, MASTERCARD, DISCOVER, and AMERICAN EXPRESS, or financing through CARE CREDIT and LENDING CLUB.

SERVICE CHARGE

If I do not pay the entire new balance within 60 days of the monthly billing date, a service charge will be added to the account for the current monthly billing period. The service charge will be a periodic rate of 1% per month. In the case of default of payment, I promise to pay any legal interest on the balance due, together with any collection costs and reasonable attorney's fee included to effect collection of this account or future outstanding accounts.

AUTHORIZATION

I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize the Dental Office to administer such medications and perform such diagnostic, photographic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the dental histories are correct to the best of my knowledge. I grant the right to the dentist to release my dental histories and other information about my dental treatment to third party payers and/or other health professionals.

ELECTRONIC SIGNATURE AGREEMENT
Date Today

MonthDayYear
Date
Signature of Patient or Representative (please hold down mouse button and sign)*

Clear

Consent For Use And Disclosure of Health Information

Ivey Oral & Facial Surgery
Section A: Patient/Legal Representative Giving Consent
Name:*
Address:
Phone Number*
Please enter a valid phone number.
SSN:
Section B: Patient/Legal Representative Giving Consent (Please read the following statements carefully)
Purpose of Consent: By signing this form, you consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before deciding to sign this form. Our Notice provides a description of our treatment, payment activities, healthcare operation, the uses and disclosures we may make of your protected health information, and of other important matters concerning your protected health information. A copy of our full Notice of Privacy Practices is available on our website. We encourage you to read it carefully and completely before signing.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions to your Notice, at any time by contacting any member of Ivey Oral & Facial Surgery team by: (phone) 303-493-1933, (fax) 303-493-1934 or by coming to our office at 14000 E. Arapahoe Rd., Ste. 320, Centennial, CO 80112.

Right to Revoke: You have the right to revoke this Consent at any time by giving us written notice of your revocation. 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 continue treating you if you revoke this Consent.
Acknowledgement:*
Patient Name*
Representatives Relationship to Patient (if applicable)
Date Today

MonthDayYear
Date
Signature of Patient or Representative (please hold down mouse button and sign)*

Clear

Communication Consent Form

Ivey Oral & Facial Surgery
Patient Name:*
I authorize the office of Ivey Oral & Facial Surgery to speak with the following individuals about my care:
Name
Relationship
Phone Number
Please enter a valid phone number.
Name
Relationship
Phone Number
Please enter a valid phone number.
Name
Relationship
Phone Number
Please enter a valid phone number.
Please be aware: if you choose to leave the above section blank, we will be unable to discuss your treatment, appointments, billing information, etc. with anyone who may call on your behalf.

Social Media Authorization

Ivey Oral & Facial Surgery
I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, movies, or videos of the patient named above by Ivey Oral & Facial Surgery.

I also grant Ivey Oral & Facial Surgery the right to edit, use, and reuse said products for nonprofit purposes: including use in print, on the internet, and all other forms of media. I also understand that no royalty, fee, or other compensation shall become payable to me by reason of such use. I also hereby release Ivey Oral & Facial SurgeryIvey Oral & Facial Surgery from all claims, demands, and liabilities whatsoever in connection with the above.
Do you accept participation in the Social Media Authorization*

I ACCEPTI DECLINE
Signature of Patient or Representative*

Clear
Should be Empty:

New Patient Form

Insurance Information

Primary Insured

Secondary Insured

Emergency and Pharmacy Information

Person to Contact In Case of Emergency

Pharmacy Information

Health History

Patient Acknowledgement

Financial Policy

Consent For Use And Disclosure of Health Information

Communication Consent Form

Social Media Authorization