Patient Registration

PATIENT REGISTRATION INFORMATION

Mr. Mrs. Ms. Dr.

Patient First Name

Middle Initial

Patient Last Name

Patient Nickname

Gender

Male Female

Date of Birth

Age

SSN

Driver's License #

Email

Address

City

State

Zip Code

Home Phone

Cell Phone

Marital Status

Employment Status

Full Time Part Time Retired Not Employed

Employer

Occupation

Business Phone

Student Status

Full Time Part Time Not a Student

School

School Address

City

State

Zip Code

Pharmacy

Pharmacy Telephone

Address

City

State

Zip Code

Have you ever been a patient in our practice?

Yes No

Has a family member ever been a patient in our practice?

Yes No

Referred By First Name

Referred By Last Name

Referral Tel #

Dentist First Name

Dentist Last Name

Dentist Tel #

Primary Care Physician First Name

Primary Care Physician Last Name

Physician Tel #

Orthodontist First Name

Orthodontist Last Name

Orthodontist Tel #

Please list any other Specialists involved in your care.

Nearest relative not living with you First Name

Nearest relative not living with you Last Name

Relative Phone

Personal Payment Type

Cash Check Credit Card

Who will be responsible for your account?

Other

Responsible Person First Name

Responsible Person Last Name

SSN

Date of Birth

Age

Telephone

Address

City

State

Zip Code

Employer

Business Phone

Spouse or other guarantor information

Please check here if information is different from above

First Name

Last Name

SSN

Date of Birth

Relation

Telephone

Address

City

State

Zip Code

Employer

Business Phone

Emergency Contact

First Name

Last Name

Home Phone

Work Phone

Cell Phone

Insurance Information

Is your insurance a PPO or HMO plan?

Yes No

Primary Dental Insurance Company

Primary Policy Holder

Relation

Gender

Male Female

SSN

Date of Birth

Address

City

State

Zip Code

Telephone

Primary Policy Holder Employer

Business Address

City

State

Zip Code

Business Telephone

Insurance Company Name

Insurance Company Address

City

State

Zip Code

Telephone

Policy I.D. #

Group #

Group Name

Secondary Dental Insurance Company

Do you have secondary dental insurance?

Yes No

Secondary Policy Holder

Relation

Gender

Male Female

SSN

Date of Birth

Address

City

State

Zip Code

Telephone

Secondary Policy Holder Employer

Business Address

City

State

Zip Code

Business Telephone

Insurance Company Name

Insurance Company Address

City

State

Zip Code

Telephone

Policy I.D. #

Group #

Group Name

Primary Medical Insurance Company

Medical Policy Holder

Relation

Gender

Male Female

SSN

Date of Birth

Address

City

State

Zip Code

Telephone

Policy Holder Employer

Business Address

City

State

Zip Code

Business Telephone

Insurance Company Name

Insurance Company Address

City

State

Zip Code

Telephone

Policy I.D. #

Group #

Group Name

Secondary Medical Insurance Company

Do you have secondary medical insurance?

Yes No

Secondary Medical Policy Holder

Relation

Gender

Male Female

SSN

Date of Birth

Address

City

State

Zip Code

Telephone

Policy Holder Employer

Business Address

City

State

Zip Code

Business Telephone

Insurance Company Name

Insurance Company Address

City

State

Zip Code

Telephone

Policy I.D. #

Group #

Group Name

Health History

Reason for today's office visit?

Height

Weight

Have there been any changes to your general health in the past year?

Yes No

If yes, please describe

Are you under the care of a physician?

Yes No

Date of last visit?

Have you had any illness, operation, or have been hospitalized in the past five years?

Yes No

If yes, please describe

Do you have unhealed/recurrent injuries, ulcers, inflamed areas, growths or sore spots in or around your mouth?

Yes No

If yes, please describe where

Do you have a prosthetic (artificial) joint?

Yes No

If yes, please describe location and date

Do you have an artificial heart valve?

Yes No

Do you require pre-medication?

Yes No

Please list medication

Have you had or do you currently have the following:

Rheumatic fever?

Yes No

Damaged heart valve?

Yes No

Mitral valve prolapse?

Yes No

Heart murmur?

Yes No

High blood pressure?

Yes No

Low blood pressure?

Yes No

Sycope (fainting)?

Yes No

Chest pain/Angina?

Yes No

Irregular heart beat?

Yes No

Cardiac pacemaker?

Yes No

Heart surgery?

Yes No

Heart attack?

Yes No

Pneumonia, bronchitis?

Yes No

Chronic cough?

Yes No

Persistent swollen neck glands?

Yes No

Asthma?

Yes No

Hay fever?

Yes No

Sinus Infections?

Yes No

Snoring?

Yes No

Sleep apnea?

Yes No

Difficulty breathing?

Yes No

Other lung trouble?

Yes No

Tuberculosis?

Yes No

Emphysema?

Yes No

Do you smoke?

Yes No

How many packs/day?

Do you use chewing tobacco?

Yes No

Blood transfusion?

Yes No

Blood disorder/ anemia?

Yes No

Bleeding tendency?

Yes No

Easy Bruising

Yes No

Liver disease?

Yes No

Stomach ulcers?

Yes No

Infectious Mononucleosis?

Yes No

Gallbladder trouble?

Yes No

Convulsions/Seizures/Epilepsy?

Yes No

Stroke?

Yes No

Fainting Spells?

Yes No

Thyroid trouble?

Yes No

Diabetes?

Yes No

Low blood sugar?

Yes No

Kidney trouble

Yes No

Are you on dialysis?

Yes No

Arthritis/Joint disease?

Yes No

Osteoporosis/Osteopenia?

Yes No

Contagious diseases?

Yes No

Delay in healing?

Yes No

Tumor or growth?

Yes No

Radiation or Chemotherapy?

Yes No

Chronic fatigue/night sweats?

Yes No

Are you on a diet?

Yes No

A history of drug abuse?

Yes No

A history of alcohol abuse?

Yes No

Contact lenses?

Yes No

Eye disease/glaucoma?

Yes No

Mental health problems?

Yes No

Removable dental appliance?

Yes No

Pain/Clicking of jaw/TMJ?

Yes No

Medications

Are you taking any of the following?

Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginkgo biloba, Aggrenox, Pradaxa, Fish oil)?

Yes No

Any natural product, herbal supplement or homeopathic remedy?

Yes No

Have you ever taken diet pills?

Yes No

Are you taking, or have you ever taken bone density medications, RANKL inhibitors or bisphosphonates such as Denosumab, Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Reclast,
or Evista in the past 12 years?

Yes No

Please list any other medications you are currently taking (medication name, dosage & frequency)

Allergies/ Reactions

Are you allergic to, or had a reaction to any of the following:

Aspirin?

Yes No

Codeine?

Yes No

Penicillin?

Yes No

Other Antibiotic?

Yes No

If yes, please list:

Sulfa drugs?

Yes No

Local Anesthetic (Novacain)?

Yes No

Other Medications?

Yes No

Please list medication allergies

Latex?

Yes No

Soy?

Yes No

Egg/Yolk?

Yes No

Sulfites?

Yes No

Sodium pentothal, Valium, or other tranquilizers?

Yes No

Is there a family history of the following?

Cancer

Yes No

Heart disease

Yes No

Diabetes

Yes No

Anesthetic problems

Yes No

Is this visit related to an accident?

Yes No

Date of Injury

Please check all that apply

Automobile

Work Related

Other

Insurance company handling this claim

Claim Number

Name of Attorney/ Adjustor

Telephone

For Women Only

Is there a possibility of pregnancy?

Yes No

Trimester

First Second Third

Expected delivery date

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

WARNING: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician for assistance regarding additional methods of birth control.

FORM COMPLETION

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my surgeon, or any other member his/her staff, responsible for any errors or omissions that I have made in the completion of this form.

Patient Signature (Parent or Guardian if minor):

Clear

Clear

Date:

FINANCIAL POLICY & IMPORTANT INFORMATION

Please read the following Financial & Insurance Policy in regards to treatment rendered by Craig E. Vigliante, M.D., D.M.D., Michael T. Gocke, D.D.S., and Michael P. McAdams, D.D.S., at Virginia Advanced Surgical Arts, PLLC.

Our Courtesy Service to You Includes:

1. Verifying your dental insurance to advise you of estimated benefits available to you. PLEASE NOTE: Verification of benefits does not guarantee payment by your insurance company. Therefore, you should also verify and understand your insurance benefits.
2. Filing your dental insurance with your dental insurance carrier.

Our Expectations of You the Patient or Guarantor:

1. Co-payments for treatment rendered are due the day the service is delivered.
2. Professional service fees are charged to the patient, NOT YOUR INSURANCE COMPANY. Your insurance company has no obligation to pay for our services; your insurance company’s obligation is to you, the policy holder. You are responsible for payment of your account within the time limits of our financial policy. We will try to assist you with any problems concerning your insurance.

Cancellation & No-Show Policy:

Our goal is to provide quality individualized care in a timely manner. Late cancellations and No-Shows (includes arriving more than 15 minutes late) create inconvenience and prevent scheduling of other patients who need access to medical care in a timely manner. Patients who do not show up for their surgical appointment or provide less than 48 hours in advance cancellation notice will be subject to a $500.00 NO SHOW fee. This fee will not be submitted to insurance. It is your responsibility and must be paid in full.

Please Note:

1. We will do our best to estimate what your insurance will pay for services. However, this is an estimate. Some plans base an amount of benefit on a schedule of fees arbitrarily developed by insurance companies. For this reason, you may receive a lower percentage of the reimbursement indicated in your dental plan. For example, if your plan states that it will pay 80% of the usual and customary cost per procedure, it means 80% of the fee determined by the insurance company, and not the actual fee charge by our practice. The patient is ultimately responsible for what the insurance does not cover, if applicable. If you have any questions, please feel free to ask one of our office administrators.
2. All accounts over ninety (90) days will be considered past due.
3. Past due accounts are subject to eighteen percent APR (18%) of 1.5 monthly finance charges.
4. Past due accounts may be referred to our collection agency for collection. In the event of default on our account, you will be responsible for thirty-three and one-third percent (33-1/3 %) attorney collection fee as well as any and all collection agency charges.
5. This office will accept the following instruments of payment for services rendered: Visa, MasterCard, Discover, American Express, Cash, Certified Check, Personal Checks ($500.00 or less) and CareCredit.
6. Personal checks that are returned due to “insufficient funds” are subject to a $50.00 service fee.

I have read and understand the Financial Policy and Insurance Policy for Virginia Advanced Surgical Arts, PLLC. I agree to be responsible for payment and all terms for services rendered on my behalf or that of my dependents.

Patient Signature (Parent or Guardian if minor):

Clear

Clear

Date:

HIV/HEPATITIS B or C TESTING

As a patient, please be advised that in accordance with Section 32.1-45.1 of the Code of Virginia, 1950, as amended, that if the provision of health care services to the patient exposes any person employed by or under the direction and control of this facility or any other healthcare provider, to the patient's body fluids in a manner which may transmit immunodeficiency virus or HIV or Hepatitis B or C viruses, then the patient will be deemed to have consented to testing for infection with HIV or Hepatitis B or C viruses, and the release of such test results to the person(s) exposed.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Click on the hyperlink to obtain a copy:

Virginia Advanced Surgical Arts, PLLC Privacy Practices

I hereby acknowledge that a copy of the patient Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

HIPAA Authorization – Please choose ONE of the following:

Patient ONLY – I understand that staff at Virginia Advanced Surgical Arts, PLLC may ONLY speak with me and the doctors involved in my treatment plan; in regards to information about my appointments, treatment, results, insurance, billing, & etc. Virginia Advanced Surgical Arts, PLLC has permission to disclose my medical information to the following (For patients over 18 years old that would like to give access of their medical information to a family member, or other individuals or organization):

Name

Relationship to Patient

Name

Relationship to Patient

The release of information will remain in effect until terminated by me in writing.

HEALTH NET/TRICARE/CHAMPUS HEALTHCARE PROGRAM NON-PARTICIPATION DISCLOSURE

We are happy to learn of you obtaining dental, oral and maxillofacial professional services from Virginia Advanced Surgical Arts. However, please note that our Practice is not a participating provider in the Health Net/Tricare/Champus program. In an effort to address billing limitations which may apply to Health Net/Tricare/Champus non-participating providers, we have found it necessary to identify Health Net/Tricare/Champus program beneficiaries upon their initial contact with our Practice, to inform them of our Practice Policy, prior to being treated as a patient.

Please indicate below if you are currently receiving benefits under any Health Net/Tricare, Champus healthcare program. If you are, please check the “YES” box within Part A, and complete Part B. Please note that our willingness to provide healthcare services to you is expressly conditioned upon the fact that you are either (1) not a Health Net/Tricare/Champus, or (2) to submit a letter and any other documentation reasonably required by Health Net/Tricare/Champus to waive the balance billing limitation on all services that we may provide to you.

PART A – Please check one of the following:

NO, I am not receiving benefits under any Health Net/Tricare/Champus healthcare program. Through my signature below, I agree to promptly inform the Practice of any change in this status prior to receiving professional services from the Practice, and to complete an updated version of this form, upon the Practice’s request, due to this status change. YES, I am receiving benefits under one or more Health Net/Tricare/Champus healthcare programs, I hereby acknowledge and agree to the conditions indicated above and within Part B of this form regarding the provision of professional services from the Practice, and have completed Part B in its entirety.

PART B – Only complete this section if you marked “YES” within Part A.

I am currently covered by the following Health Net/Tricare/Champus healthcare programs, and have provided a copy of my beneficiary cards to the Practice indicating my status under such programs.

I hereby acknowledge that to the best of my information, knowledge and belief that the information I have provided in Part A and Part B (if applicable) of this form is true and accurate, and herby agree to promptly notify the Practice concerning any change in such information prior to receiving professional services from this Practice.

I understand and agree that my initials below and my signature on this form indicate my agreement to submit a letter and/or other reasonable documentation required by the relevant Health Net/Tricare/Champus healthcare contractor(s), with a copy to the Practice, indicating my desire for Health Net/Tricare/Champus to waive the balance billing limitations which may be imposed upon the Practice for procedures which may be performed on me by the Practice. The Practice agrees to provide me with a letter which I may consider utilizing for this submission. I agree to promptly provide the Practice a copy of any written correspondence I may receive from Health Net/Tricare/Champus healthcare concerning my request(s) for the aforementioned waiver.

I acknowledge and agree that this requirement shall be an express condition to the Practice’s willingness to accept me as a patient, and that my failure to either meet these conditions or failure of the Health Net/Tricare/Champus healthcare contractor to accept my written for a waiver may result in the Practice’s unwillingness to treat me. I understand that the Practice may pursue any other remedies available to it under applicable law based upon errors or omissions in this form, or any failure to meet the above conditions. Finally, I agree that such actions by the Practice shall not result in my abandonment as a patient, and that the Practice may waive these requirements for certain Health Net/Tricare/Champus healthcare programs, in the Practice’s sole discretion.

Please Initial

MEDICARE OPT-OUT NOTIFICATION

We are happy to learn of you obtaining dental, oral and maxillofacial professional services from Virginia Advanced Surgical Arts. However, please note our Practice has Opt-Out of Medicare; therefore, we will not be able to file a claim for you and/or you cannot file a claim to Medicare for reimbursement. In an effort to address billing limitations which may apply to Medicare, we have found it necessary to identify our Medicare beneficiaries upon their initial contact with our Practice, to inform them of our Practice’s Medicare Opt-Out Policy, prior to being treated as a patient. Please note that our willingness to provide healthcare services to you is expressly conditioned upon the fact that you are fully aware that we are Opt-Out of Medicare and a claim will not be generated, and you will not be reimbursed by Medicare.

• I acknowledge that Medigap plans do not, and that other supplemental insurance plans (such as FEP) may elect not to, make payments for services furnished by a physician or practitioner under the “opt-out” contract.
• I agree to be responsible for payment.
• I acknowledge that the physician or practitioner is not limited to the amount that he or she may charge for services rendered.

I DO receive Medicare Benefits I DO NOT receive Medicare Benefits

AUTHORIZATION

I authorize my surgeon and his/her staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x-rays required as necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers.

Patient Signature (Parent or Guardian if minor):

Clear

Clear

Date:

IF PATIENT IS A MINOR

Form signed by:

Relationship to Patient: