California Oral Surgery and Dental Implant Center: Patient Registration

California Oral Surgery & Dental Implant

7677 Center Ave, Ste 409 Huntington Beach, CA 92647 | Phone: (714) 897-3543 | Fax: (714) 897-0505 | info@oralsurgerycalifornia.com | www.oralsurgerycalifornia.com
Patient Registration Packet
*** This form is designed to be completed online. If you're unable to fill it out digitally, you may print a copy instead. [Click here to print the form.] ***
PERSONAL & CONFIDENTIAL INFORMATION
Name*
Social Security*
Date Of Birth*

MonthDayYear
Age*
Address*

Address

Street Address Line 2

CityState

Zip
Home Phone*
Patient's Email*
example@example.com
Referred By
Dentist
Orthodontist
Physician
Student*

YesNo
Sex*

MaleFemale
Marital Status*
Spouse Name
Patient's Employer
School Attending
Employer / School Address

Address

Street Address Line 2

CityState

Zip
Work Phone
Please enter a valid phone number.
Drivers License Number
Closest Relative
Relative's Phone
INSURANCE INFORMATION
Primary Insurance Company Name
Policy Number
Group Number
Work Name
Employee's Name
DOB

MonthDayYear
Date
Social Security Number
Relation
Sex

MaleFemale
Secondary Insurance Co Name
Policy Number
Group Number
Work Name
Employees Name
DOB
Soc Sec
Relation
Sex

MaleFemale
MEDICAL HISTORY

Please Read And Answer Carefully
Have you had or do you currently have any of the following? (Select all that apply)*

Chest Pain / AnginaHeart MurmurRheumatic FeverHigh Blood PressureLow Blood PressureAnemiaSeizuresRadiation TreatmentShortness of BreathHeart AttackLung TroubleLiver TroubleHeart SurgeryKidney TroubleGlaucomaHepatitisHigh CholesterolDiabetesBleeding ProblemsIrregular HeartbeatDepressionAsthmaPeptic or Stomach UlcersTooth ExtractionsThyroid ProblemsAIDS or HIVDamaged Heart Valves/MitralJoint ReplacementNone of the above
List the medicines you are allergic to
List the medicines you are taking
Have you ever had a high temperature or other problems while under general anesthesia?*

YesNo
Have you been treated by a physician recently?*

YesNo
Have you ever been admitted to the hospital?*

YesNo
Are you taking any medicines now?*

YesNo
Are you pregnant?*

YesNo
Do you smoke?*

YesNo
How Much? *
Have you ever taken Fen-Phen?*

YesNo
Are you taking any drugs not prescribed by a physician? (e.g., aspirin)*

YesNo
Do you take any illicit drugs? No Yes (e.g., marijuana, cocaine, heroin, etc)*

YesNo
Do you have a cardiac pacemaker?*

YesNo
Have you ever taken bisphosphonates?(e.g., Fosamax®, Boniva)*

YesNo
Are there any other medical problems or conditions that you think we should know about?*

YesNo
If yes please explain*
I AUTHORIZE RELEASE OF ANY INFORMATION RELATING TO THIS CLAIM. I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL COSTS OF DENTAL TREATMENT. I HEREBY AUTHORIZE PAYMENT DIRECTLY TO CALIFORNIA ORAL SURGERY & DENTAL IMPLANT CENTER INSURANCE BENEFITS OTHERWISE PAYABLE TO ME.

I hereby certify that I have answered the above questions correctly and have had a chance to ask questions.
Patients Signature or parent if patient is a minor*

Clear
Date*

MonthDayYear
Date
Notice Of Privacy Practices
This notice describes how your health information may be used and disclosed and how you can access this information. Please review it carefully.

At California Oral Surgery & Dental Implant Center, we have always kept your health information secure and confidential. A new law requires us to continue maintaining your privacy, to give you this notice, and to follow the terms of this notice.

The law permits us to use or disclose your health information to those involved in your treatment. For example, a review of your file by a specialist doctor whom we may involve in your care.

We may use or disclose your health information for payment of your services. For example, we may send a report of your progress to your insurance company.

We may use or disclose your health information for our normal healthcare operations. For example, one of our staff will enter your information into our computer.

We may share your medical information with our business associates, such as a billing service. We have a written contract with each business associate that requires them to protect your privacy.

We may use your information to contact you. For example, we may send newsletters or other information. We may also want to call you and remind you about your appointments. If you are not home, we may leave this information on your answering machine or with the person who answers the telephone.

In an emergency, we may disclose your health information to a family member or another person responsible for your care.

We may release some or all of your health information when required by law. If this practice is sold, your information will become the property of the new owner. Except as described above, this practice will not use or disclose your health information without your prior written authorization.

You may request in writing that we not use or disclose your health information as described above. We will let you know if we can fulfill your request.

You have the right to know of any uses or disclosures we make with your health information beyond the above normal uses.

As we will need to contact you from time to time, we will use whatever address or telephone number you prefer.

You have the right to transfer copies of your health information to another practice. We will mail your files for you.

You have the right to see and review a copy of your health information, with few exceptions. Give us a written request regarding the information you want to see. If you also want a copy of your records, we may charge you a reasonable fee for the copies.

You have the right to request an amendment or change to your health information. Give us your request to make changes in writing. If you wish to include a statement in your file, please give it to us in writing. We may or may not make the changes you request but will be happy to include your statement in your file. If we agree to an amendment or change, we will not remove nor alter earlier documents but will add new information.

You have the right to receive a copy of this notice.

If we change any of the details of this notice, we will notify you of the changes in writing.

You may file a complaint with the Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, Washington, DC 20201. You will not be retaliated against for filing a complaint.

However, before filing a complaint, or for more information or assistance regarding your health information privacy, please contact our Privacy Officer, Shannon Record, at (714) 897-3543. This notice goes into effect as of April 14, 2003.
Acknowledgment*

I have received a copy of the California Oral Surgery & Dental Implant Center Notice of Privacy Practices.
PRINT NAME*
PATIENT RESPONSIBLE PARTY SIGNATURE*

Clear
DATE*

MonthDayYear
Date
If signing as a parent or guardian please note the name of the patient
Financial Policy
Financial Policy

At California Oral Surgery & Dental Implant Center, our highest priority is our patients. We find the financial matters to be the most awkward part of doctor-patient relationships. Our office strives to help our patients manage the financial complexity of health care. You, the patient, are ultimately financially responsible for all treatment provided. Our office accepts many forms of payment, including cash, check, Visa, Mastercard®, and Discover. We also offer financing through CareCredit®

Your Insurance Coverage

Our office accepts many different types of dental insurance. We are happy to assist you in utilizing your insurance, but ultimately, your insurance is an agreement between you and your insurance company. Our office will often help by obtaining an estimate after your insurance benefits have been verified. This is an estimate of coverage, and you are ultimately responsible for understanding your insurance coverage and plan. You are also responsible for any and all treatment provided regardless of your insurance. All copays are due at the time of service.

Out-of-Network Insurance

Some insurance companies require preauthorization or review. If you decide to proceed with your treatment before your insurance company has completed their preauthorization, you will be required to pay in full when the services are rendered.

Many patients choose our office even if their insurance is out-of-network. Our staff will assist you in billing your insurance for any treatment provided in our office. If there is a difference in your insurance's contracted fee and our fees, than you are ultimately responsible for that difference.

If your insurance company has failed to make payment for any reason within 60 days, your account will be due in full. We will be happy to help with additional billing and assist you in your reimbursement from your insurance carrier. If you have any questions regarding your account, please contact our office.

My signature below indicates that I have read and/or had explained to me the above statement, that I understand it, and that I agree to abide by the conditions set forth therein.
PATIENT RESPONSIBLE PARTY SIGNATURE*

Clear
DATE*

MonthDayYear
Date
NAME OF INSURANCE CARRIER*
Should be Empty:

California Oral Surgery & Dental Implant

Patient Registration Packet

PERSONAL & CONFIDENTIAL INFORMATION

INSURANCE INFORMATION

MEDICAL HISTORY

Notice Of Privacy Practices

Financial Policy