Atlanta Oral & Facial Surgery - Reg Financial HIPAA Form

Atlanta Oral & Facial Surgery PATIENT REGISTRATION

PLEASE COMPLETE THE FOLLOWING CONFIDENTIAL INFORMATION

Reason for visit *:

Who recommended treatment ?

This is my :

Dentist

Orthodontist

Physician

Is the person who recommended treatment also the one who referred you to AOFS ?

Yes

No

If no, would you please share how were you referred to AOFS ?

Internet

Insurance

Mailer

Friend/Patient

Other

Have you or anyone in your family ever been seen by a doctor in our practice ?

Yes

No

Atlanta Oral & Facial Surgery PATIENT REGISTRATION

Conclusion

I understand the importance of a truthful and complete Health History to assist my doctor in providing the best care. I verify that the information provided is true and accurate to the best of my knowledge.

Patient / Guardian Signature *:

(Please click below to draw/upload sign)

(Your IP Address :IP:34.239.150.167 )

HIPAA and Assignment of benefits

HIPAA Privacy Practices Acknowledgement and Permission to Release Health Care Information

Patient Name or Guarantor if minor *:

Relationship to patient :

Other *:

I,__________ hereby authorize Atlanta Oral & Facial (Patient Name or Guarantor if minor) Surgery to use and/or disclose protected healthcare information either medical or financial for __________, with the following people:

Relationship to patient

First :

Last :

Other *:

Relationship to patient :

First :

Last :

Other *:

Relationship to patient :

First :

Last :

Other *:

Relationship to patient :

First :

Last :

Other *:

I give permission to leave messages on this phone and/or email *:

I authorize use of patient medical and/or other information necessary to process insurance

Per HIPAA regulations, the medical information may be discussed with the patient’s dentist, medical doctor and laboratory to best offer continuity of care.

I have been given the opportunity to read HIPAA regulations and understand the contents. I understand that Atlanta Oral and Facial Surgery will disclose this information only to provide quality care and payment for services.

Signature of patient *:

(Please click below to draw/upload sign)

(Your IP Address :IP:34.239.150.167 )

Atlanta Oral & Facial Surgery – Assignment of Benefits (Revised 12.18.17)

I __________ The undersigned (the “Patient”), having healthcare benefit coverage through a group (including a self-funded and employer/employee benefit plan), Medicare, Medicaid and/or individual healthcare plan (collectively, the “Plan”), hereby assigns and conveys directly to Atlanta Oral & Facial Surgery (the “Provider"), the right to pursue payment for benefits and take any necessary steps, including pursing administrative appeals and remedies, filing suit and all causes of action wholly in my stand for benefit payment of all medical benefits otherwise payable to the Patient for medical services, treatments, therapies, and/or medications rendered or provided by the Provider under the Plan, regardless of the Provider's managed care network participation status. The Patient hereby appoints the Provider, Atlanta Oral & Facial Surgery and/or the Provider’s appointed business associates, the Patient’s rights, title, and interests in and to, and related to the recovery of, any and all benefits which the Patient is entitled to receive under the Plan or insurance policy, and authorizes the Provider to release all medical information necessary to pursue and process the Patient’s benefits and claims thereunder.

I certify that the health insurance information that I provided is accurate and that I am responsible for keeping it updated. I hereby authorize provider to submit claims, on my and/or my dependent’s behalf, to the benefit plan (or its administrator). I also hereby instruct my benefit plan (or its administrator) to pay the Provider directly for services rendered to me or my dependents. To the extent that my current policy prohibits direct payment to provider, I hereby instruct and direct my benefit plan (or its administrator) to provide documentation stating such non-assignment to myself and the provider upon request. Upon proof of such non-assignment, I instruct my benefit plan (or its administrator) to make the check payable to me and mail it directly to the provider. I am fully aware that having health insurance does not absolve me of my responsibility to ensure that my bills for all professional services from the Provider are paid in full. I also understand that I am responsible for all amounts not covered by my health insurance, including co-payments, co-insurance, and deductibles. I understand, agree and hereby certify that I am obligated to pay, as charged and billed for global service charges, regardless if the above services are covered under my health insurance or plan. I understand that "Deductible” is defined, under the Uniform Glossary from ERISA & the Patient Protection & Affordable Care Act (ACA) as: “7/ie amount you owe for healthcare serv/ces your health insurance or plan covers before your health insurance or plan begins to pay,” and that I have no knowledge of any plan exclusion or limitation for the charges for healthcare services rendered by the above listed provider, in case that I can’t afford to pay for 100% deductible. I understand the payments are due at the time of the services unless otherwise applicable to any PPO or ACA discount once my claim for benefits is processed in full compliance with plan terms and governing laws. I understand I am fully protected against any unexpected medical bills or charges by my provider’s applicable ACA or indigency discount policy; including any non-compliant or arbitrary and capricious PPO Discounts or Re-pricing Discounts received from my health insurance plan. My satisfaction is guaranteed in connection with my provider’s proactive reasonable efforts to collect or make a good faith determination for ACA Discount qualifications solely based on my unique ability to pay and individual health need. I hereby assign billed charges for healthcare services rendered as my legal claims to the above listed provider as full payment, as my authorized representative, and an ERISA or ACA claimant, to claim or legally pursue proper payment of benefits from my health insurance or plan.

I hereby authorize the Provider, Atlanta Oral & Facials Surgery, its attorneys or other designated business associate. to: (1) release any informationnecessary to my health benefit plan (or its administrator) regarding my illness and treatments; (2) process insurance claims generated in the courseof examination or treatment; (3) To file and participate in any administrative or judicial review process; (4) to give the provider and its attorneysstanding to pursue payment and file suit for benefits and any fiduciary breach and all causes of action available under ERISA and Section 502, 27 §U.S.C. 1132(a). (5) to pursue all necessary benefit payments, appeal rights, remedies and all causes of action, wholly in my stead; (6) to pursue aclaim for benefits and to recover all applicable penalties for any fiduciary breach or failure by my plan, its fiduciary and/or its claims administrator tocomply with 29 USC § 1132 and (7) allow a photocopy of my signature to be used to process insurance claims. This order will remain in effect untilrevoked by me in writing. I authorize Provider or Atlanta Oral & Facial Surgery, its attorneys, or designated business associate to make any request,fiIe and obtain appeals information, receive any notice in connection with my healthcare services, benefits, appeal, take legal action or other rights,whoIIy in my stead. Further, I hereby authorize my plan administrator, fiduciary, insurer, and/or attorney to release to the above-named health careprovider or its designated business associated any and all relevant Plan and claim documents, requested disclosures, complete insurance poIicy,and/or settlement information upon written request from the provider, its attorneys or designated business associates in order to secure and claimsuch medical benefits. I authorize the release or disclosure of my protected health information to my authorized representative in order to secureand claim medical benefits due; (1) obtain information or submit evidence regarding the claim to the same extent as me; (2) make statements aboutfacts or law; (3) act as my authorized representative in connection with filing, providing or receiving notice of any claim or appeal proceedings, toinclude any external review by applicable state or Federal External Review Process. I authorize my designated authorized representative to makeany request; to present or to produce evidence; to file and obtain any claim, appeal or external review information; to receive any notice inconnection with my claim, appeal or external review; wholly in my stead. I understand that I will be held financially responsible for all feesaccumulated for collection agency fees. Administrative fees, attorney fees and court costs incurred by the provider listed above for any delinquentaccount requiring outside collection assistance, to the fullest extent of the law. I understand revocation of this appointment will not affect any actiontaken in reliance on this appointment before my written notice of revocation is received. Unless revoked in writing, this assignment is valid for anyand all requested administrative and judicial reviews rightfully due me under my governing plan or policy and to the fullest extent permitted by law. A photocopy of this assignment is to be considered valid, the same as if it was the original. I understand that, by signing this form, I am confirming myappointment of my authorized representative, the scope of my authorized representative’s authority, and the option of revoking of this appointment. I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT

Patient / Guardian / Insured Signature *:

(Please click below to draw/upload sign)

(Your IP Address :IP:34.239.150.167 )

Employer Group Name Covering Benefits

Heart Attack (myocardial infarction) Yes No
Coronary Artery Disease Yes No
Congestive Heart Failure Yes No
Irregular rate or rhythm Yes No
Pacemaker or Implanted Defibrillator Yes No
Heart valve issues Yes No
Artificial heart valve Yes No
Frequent fainting Yes No
Chest pain or shortness of breath Yes No
Heart surgery (Bypass, Stents, etc) Yes No
Require pre-medication Yes No
Other Yes No

Sickle Cell Disease or Trait Yes No
Hemophilia or Von Willebrand Disease Yes No
Low Platelet Yes No
Other Yes No

HIV / AIDS Yes No
Hepatitis B or C Yes No
Sexually Transmitted Disease Yes No
Other Yes No

Atlanta Oral & Facial Surgery PATIENT REGISTRATION

PLEASE COMPLETE THE FOLLOWING CONFIDENTIAL INFORMATION

Atlanta Oral & Facial Surgery PATIENT REGISTRATION

PATIENT INFORMATION

Atlanta Oral & Facial Surgery PATIENT REGISTRATION

MEDICAL INSURANCE

Atlanta Oral & Facial Surgery PATIENT REGISTRATION

DENTAL INSURANCE

Atlanta Oral & Facial Surgery PATIENT REGISTRATION

PATIENT GUARDIAN

ASSIGNMENT OF BENEFITS AND RELEASE OF MEDICAL RECORDS

Atlanta Oral & Facial Surgery PATIENT REGISTRATION

Atlanta Oral & Facial Surgery PATIENT REGISTRATION

Do you have or have you ever had any of the following medical conditions

(Please, mark Yes or No and check appropriate boxes):

Atlanta Oral & Facial Surgery PATIENT REGISTRATION

Conclusion

Financial Policy

FINANCIALLY RESPONSIBLE PARTY - Must be present at appointment

HIPAA and Assignment of benefits

HIPAA Privacy Practices Acknowledgement and Permission to Release Health Care Information

Atlanta Oral & Facial Surgery – Assignment of Benefits (Revised 12.18.17)

Hypertension / High Blood Pressure * Yes No

Neurologic / Brain Conditions * Yes No

Stomach Ulcers Yes No
Ulcerative Colitis or Chron's Disease Yes No
Other Yes No

Osteoporosis requiring medication Yes No
Artificial Joint Yes No
Other Yes No

Hyperthyroidism Yes No
Hypothyroidism Yes No
Other Yes No

FEMALE patients :
Are you pregnant, possibly pregnant, or trying to get pregnant?* (If you are taking birth control, antibiotics can interfere with the actions of oral contraceptives and additional contraceptive precautions are required.) Yes No

Do you have any other medical condition, disease, or problem not listed?* Yes No

Stroke Yes No
Date of stroke:
Other Yes No

Pulmonary / Lung Conditions * Yes No

Blood or Bleeding Disorders * Yes No

Diabetes * Yes No