Online Patient Registration

I authorize the release of all medical information to my insurance company, physician, or dentist as deemed necessary in the professional judgement of my oral surgeon. I assign all insurance benefits which I am entitled, to OM3 Oral Surgery. This assignment shall remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I understand as the patient and/or responsible party that I am financially responsible for all charges, regardless of any insurance coverage I may have. I understand and agree that if the bill is not paid in full within 30 days of the services provided, I will be charged interest at the rate of 12% per annum, compounded monthly on any unpaid balance due and I will pay that as well as the balance due. In the event it should become necessary to place for collection any unpaid balance due, I agree to pay any collection, legal, and/or court fees required in the collection process.

My Signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to: Provide and coordinate my treatment among a number of health care providers who may be involved in the treatment directly and indirectly Obtain payment from third-party payers for my health care services Conduct normal health care operations such as quality assessment and improvement activities I have been informed of my dental provider's Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations and I understand that you are required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

Patient Demographics

Basic Patient Information

Guarantor Information

Insurance Information

Primary Dental Insurance

Primary Medical Insurance

Secondary Dental Insurance

Primary Medical Insurance

Emergency Contact Information

Medical History

Medical History

Do you have or have you had any of the following diseases or problems?

Are you allergic to or have you had a reaction to:

Women

Acknowledgement of Privacy Practices