New Patient Registration Form - James & Maxillofacial Surgery

Theodore James, DDS

Diplomate of the American Board of Oral and Maxillofacial Surgery
P: 208-207-9093 | F: 208-207-9866 | E: Info@jamesomfs.com
2677 E. 17th St. STE 600, Ammon, ID 83406

Patient Registration Form

Patient Registration Form - Version 2

"*" indicates required fields

Step 1 of 8 - Patient Informations

PATIENT INFORMATION

NAME*

DATE OF BIRTH*

SOC #*

MAILING ADDRESS

GENDER

MARITAL STATUS

HOME PHONE

CELL PHONE

PARENT/PERSON RESPONSIBLE FOR ACCOUNT?

SAME AS ABOVE

NAME OF THE PARENT/PERSON RESPONSIBLE FOR THIS ACCOUNT*

RESPONSIBLE PERSON’S DATE OF BIRTH/ SOCIAL SECURITY #*

MAILING ADDRESS (RESPONSIBLE PARENT/PERSON)

HOME PHONE

CELL PHONE

EMERGENCY CONTACT INFORMATION*

DATE OF BIRTH*

PHONE*

JAMES ORAL & MAXILLOFACIAL SURGERY Theodore S. James, DDS

2677 E 17th ST. STE 600 IDAHO FALLS, ID 83406 (208) 207-9093

FINANCIAL POLICY

Thank you for choosing us as your Oral Surgeon Provider. The purpose of this policy is to empower you by giving you a clear understanding of your ﬁnancial responsibility with regard to any and all shared costs, co-pay amounts, deductibles, and any balance not paid by your insurance or employer plan.

SELF PAY
If you are uninsured, all fees are required at the time of service. We accept all major credit cards.

INSURED
We will bill your insurance for you, but patient deductibles, co-payments and coinsurance are due at the time of service. All major credit cards are accepted for your convenience. Your insurance may pay more or less than we expect and you will be responsible for any remaining balance. If we have not had a response from your insurance company within 30 days (as required by state law), you will be sent a bill for the remaining balance. We request that you take an active role in getting your insurance company to pay your claim.

INSURANCE DENIALS / SURGERY
As a safeguard, our facility will contact your insurance company to pre-authorize, pre-notify, and/or pre-certify any surgery(s) you may choose to have. This action is required by most insurance carriers but it does not result in a guarantee of payment. Please be advised that unless contractual arrangements aﬀect your liability for payment, you are responsible for your bill. Your insurance company may claim that your recommended surgical procedures lack medical necessity, are investigational, or use another form of denial tactic. By signing this form, you agree that should your insurance company deny payment for services that you have chosen to have, you will take responsibility for all charges incurred.

DELINQUENT ACCOUNTS
You agree to pay cost and/or reasonable attorney’s fees if any delinquent balance is placed with agency or attorney for collection or suit. If it becomes necessary to collect an account by legal action, the responsible party will need to pay ALL fees involved.

RETURNED CHECKS
If payment by check is returned for Non-Suﬃcient Funds, you will be charged a $20.00 fee along with the total of the check to be paid in full.

3% SERVICE CHARGE
Please note that a 3% service charge will be applied to all credit or debit card transactions and online payments.

DIVORCE
In case of a divorce, Dr. James is not party to the divorce settlement. If your ex-spouse is obligated to pay, that is up to you to enforce, not the doctor.

MISSED APPOINTMENTS
We require 24 hours’ notice for the cancellation of an appointment except in an emergency situation. After one missed appointment without 24 hours’ notice, you will be charged a $250.00 missed appointment fee.

OVERPAYMENTS
Overpayments will be returned to the patient/guarantor after completion of all insurance billing.

Thank you for trusting us with your care. Please feel free to contact our oﬃce at (208) 207-9093 with any questions you may have regarding ﬁnancial responsibilities.

Signature of Patient or Parent/Guardian*

Date*

SUMMARY OF NOTICE OF PRIVACY PRACTICES

THIS SUMMARY IS PROVIDED TO ASSIST YOU IN UNDERSTANDING THE NOTICE OF PRIVACY PRACTICES

USES AND DISCLOSURES OF HEALTH INFORMATION

We will use and disclose your health information for treatment, obtain payment, and health care operations, or for certain limited operational activities such as quality assessment, licensing, accreditation and training of students. If your information includes substance use disorder (SUD) records, those records receive additional federal protection. We may use and disclose SUD records only as permitted by law or with your written authorization.

LEGAL PROTECTIONS FOR SUD RECORDS

SUD records generally may not be used or disclosed in any civil, criminal, administrative, or legislative proceeding against you without your specific written consent or a court order, except as otherwise permitted by law.

REDISCLOSURE NOTICE

Information disclosed by us may be re-disclosed by the recipient and may no longer be protected by HIPAA, although other laws may still apply, especially to SUD records.

USES AND DISCLOSURES BASED ON YOUR AUTHORIZATION

Except as stated in more detail in the Notice of Privacy practices, we will not use or disclose your health information without your written authorization.

USES AND DISCLOSURES NOT REQUIRING YOUR AUTHORIZAITION

In the following circumstances, we may disclose your health information without your written authorization:

To family members or close friends who are involved in your health care
For certain limited research purposes
For purposes of public health and safety
To Government agencies for purposes of their audits, investigations, and other oversight activities
To Government authorities to prevent child abuse or domestic violence
To the FDA to report product defects or incidents
To law enforcement authorities to protect public safety or to assist in apprehending criminal offenders
When required by court orders, search warrants, subpoenas, and as otherwise required by law

PATIENT RIGHTS

As our patient, you have the following rights:

To have access to and/or a copy of your health information
To receive an account of certain disclosures we have made of your health information
To request restrictions as to how your health information is used or disclosed
To request that we communicate with you in confidence
To request that we amend your health information
To receive notice of our privacy practices

I request that my personal health information NOT be released to the following person(s):

I acknowledge that I have read (or had the opportunity to read if I so choose) and understand the Notice. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent, is not affected.

Patient name

Date*

Signature(Patient/Gaurdian)*

Privacy Notice: We take your privacy seriously. All information you provide is handled with strict confidentiality and used solely to support your care and treatment. We do not sell, rent, or share your personal information for marketing purposes at any time. Your data is securely stored and only accessible to authorized staff directly involved in your care.

Theodore James, DDS

Diplomate of the American Board of Oral and Maxillofacial Surgery
P: 208-207-9093 | F: 208-207-9866 | E: Info@jamesomfs.com
2677 E. 17th St. STE 600, Ammon, ID 83406

Theodore James, DDS

Patient Registration Form

Patient Registration Form - Version 2

PATIENT INFORMATION

PRIMARY DENTAL INSURANCE INFORMATION

SECONDARY DENTAL INSURANCE INFORMATION

PRIMARY MEDICAL INSURANCE INFORMATION

SECONDARY MEDICAL INSURANCE INFORMATION

MEDICAL INFORMATION

REFERING / CURRENT PHYSICIAN

ALLERGIES

GENERAL MEDICAL HISTORY

SUMMARY OF NOTICE OF PRIVACY PRACTICES

THIS SUMMARY IS PROVIDED TO ASSIST YOU IN UNDERSTANDING THE NOTICE OF PRIVACY PRACTICES

Theodore James, DDS

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