Section 1 of 6 in this document

Thank you for selecting our surgical team! We strive to provide you with the best possible care. To help us meet all your surgical healthcare needs, please fill out this form completely. If you need any assistance or have any questions, please ask our friendly staff - we will be happy to help.

Patient Full Name

Gender

Male

Female

Age

Birth Date

Cell Phone

Home Phone

Work Phone

Social Security

Email Address

Mailing Address

City

State

Zip

Employer or School

Employer or School City

Dentist Name

Physician Name

Orthodontist Name

Other Specialist

Section 2 of 6 in this document

Emergency Contact Name

Emergency Contact Relationship to Patient

Emergency Contact Cell Phone

Emergency Contact Home Phone

Responsible Party Full Name

Responsible Party Birth Date

Responsible Party Social Security

Responsible Party Cell Phone

Responsible Party Home Phone

Responsible Party Mailing Address

Responsible Party City

Responsible Party State

Responsible Party Zip

Responsible Party Employer

Responsible Party Employer City

Section 3 of 6 in this document

Dental Insurance

Primary Dental Insurance Company

Primary Dental Insurance Subscriber ID

Primary Dental Insurance Employee or Subscriber Name

Primary Dental Insured Party Relationship to Patient

Primary Dental Insured Party Employer

Primary Dental Insured Party SSN

Primary Dental Insured Party Birth Date

Secondary Dental Insurance Company

Secondary Dental Insurance Subscriber ID

Secondary Dental Insurance Employee or Subscriber Name

Secondary Dental Insured Party Relationship to Patient

Secondary Dental Insured Party Employer

Secondary Dental Insured Party SSN

Secondary Dental Insured Party Birth Date

Medical Insurance

Primary Medical Insurance Company

Primary Medical Insurance Subscriber ID

Primary Medical Insurance Employee or Subscriber Name

Primary Medical Insured Party Relationship to Patient

Primary Medical Insured Party Employer

Primary Medical Insured Party SSN

Primary Medical Insured Party Birth Date

Secondary Medical Insurance Company

Secondary Medical Insurance Subscriber ID

Secondary Medical Insurance Employee or Subscriber Name

Secondary Medical Insured Party Relationship to Patient

Secondary Medical Insured Party Employer

Secondary Medical Insured Party SSN

Secondary Medical Insured Party Birth Date

Section 5 of 6 in this document

Office Policy Regarding Payment for Treatment

I understand that Todd Cooper, DDS, Tyson Teeples, DMD, MD, Ryan Toponce, DMD, and Brandon Reddinger, DDS, and Matthew Black, DDS, utilize the trade name Columbia Basin Oral and Maxillofacial Surgeons - 512 North Young Street, Kennewick, WA 99336.

Payment Plans Availble:

I understand that payment is expected at the time services are rendered. I will pay according to the method indicated (please choose one).

We are not contracted with most insurance companies. Your insurance coverage is a contract between you and your insurance company. If we have the necessary information, we will be glad to assist you in the submission of your claim, but payment of your account is ultimately your responsibility. Any fees left unpaid by your insurance are payable by you in full upon receipt of negotiating a disputed claim. You are responsible for payment of the balance of your account regardless of payment from insurance after 60 days from your initial date of treatment. Insurance coverage is not a guarantee of payment! Insurance plans vary widely in their policy provisions and benefit amounts; therefore, the amount quoted as your co-payment should not be relied upon to be your total balance due. We can only estimate your coverage and co-payment, so your understanding of your policy is your best assurance that your claim will be properly administered.

I authorize my insurance company to release benefits to my doctor that would otherwise be paid to me. I also authorize the doctor to release any information required for the administration of my claims.

THERE IS A SERVICE CHARGE OF 1.5% PER MONTH ASSESSED ON ANY ACCOUNT BALANCE OVER 60 DAYS WITH A MINIMUM CHARGE OF $1.00 PER MONTH.

I have read and I understand the terms of payment as outlined above. I agree that in the event I default and not make payment in accordance with the terms indicated above, my account will be transferred to a collection agency and that I will be responsible for the costs of collection including reasonable attorney’s fees in an amount that can be 33% of the principal amount sued upon. I understand that there is a minimum $30 service charge for any NSF check returns and that future payments will be cash only.

I have received a copy of this offices Notice of Privacy Practices. You may contact me and leave messages by phone, mail, or e-mail.

You may discuss my account insurance or treatment with:

Medicare Information

Are you currently enrolled in any Medicare or Medicare Advantage Plan?

Yes

Signature

The above information is accurate and complete to the best of my knowledge and is only for use in my treatment, billing, and processing of insurance for benefits for which I am entitled. I will not hold Dr. Cooper, Dr. Teeples, Dr. Toponce, Dr. Reddinger, or any members of their staff responsible for any errors or omissions that I may have made in the completion of this form.

To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health, abnormal laboratory tests, or if my medicines change, I will inform the doctor at the next appointment without fail. I have had a chance to ask questions. I understand x-rays and local anesthetics may be required for treatment. I also state I read and write in English, or this information has been translated to me in my primary language.

Gender

Dental Insurance

Medical Insurance

Medical History

Allergies

Please list all other known allergies:

Please list all current medications of any kind including dosage:

Patient History

Are you in good health?

Has there been any change in your general health in the past year?

Are you under a physician's care, or have you been in the past five years, including hospitalizations and surgeries?

Have you taken Cortisone or other steroids in the past 24 months?

Have you had ophthalmic (eye) surgery in the past 8 weeks?

Have you or your family had a reaction to dental or general anesthetic?

Have you had any adverse effects from dental treatment?

When you walk up stairs or take a walk, do you ever have to stop because of pain in your chest, shortness of breath, or because you feel very tired?

Do you take or have you taken:

Have you had, or do you currently have:

Cardiovascular

Hematologic

Neural/Sensory

Gastrointestinal

Respiratory

Dermal/Skin/Joints

Endocrine

Urinary

Other Conditions

Do you wish to talk with the doctor about anything privately?

Women Only