New Patient Online Forms

RESPONSIBLE PARTY

DENTAL INSURANCE INFORMATION

SECONDARY DENTAL INSURANCE INFORMATION

MEDICAL INSURANCE INFORMATION

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

MEDICAL HISTORY FORM

For the following questions, answer yes or no. whichever applies Your answers are for our records only and will be kept confidential.

WOMEN

I have read and understand the above. Any questions I had about this form have been answered and I understand the answers. I understand it is my responsibility to fill out the form correctly and completely.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

**(Patients 18 Years and over Must Sign This Area)**

Acknowledgment of Receipt of Notice of Privacy Practices

Purpose: This form is used to obtain acknowledgment of Receipt of our Notice of Privacy Practices or to document our good faith effort to obtain that acknowledgment.

You May Refuse to Sign This Acknowledgement

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

**(Patients 18 Years and over Must Sign This Area)**

AUTHORIZATION TO RELEASE INFORMATION

Purpose: This form is used to obtain authorization to release information regarding yourself covered under the Privacy Act to people other than yourself.

FOR OFFICE USE ONLY

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

**(Patients 18 Years and over Must Sign This Area)**

Medicare Private Contract

THIS FORM TO BE COMPLETED BY MEDICARE BENEFICIARIES ONLY

A provision in the Social Security Act permits Medicare beneficiaries and physicians to contract privately outside of the Medicare program. A “Private Contract” is a contract between a Medicare beneficiary (Patient) and a physician or other practitioner (Dentist) who has opted out of Medicare. In a private contact, the Medicare beneficiary agrees to give up Medicare payment for services furnished by the Dentist and to pay the Dentist without regard to any limits that would otherwise apply to what the Dentist could charge. Patients and Dentists who take advantage of this provision are not permitted to submit claims or to expect payment for those services from Medicare.

This agreement is between Nashville Oral Surgery (Dr. Mack & Dr. Thomas) with offices located in Nashville and Brentwood, and the Patient indicated above who is a Medicare beneficiary seeking services. The Patient has been informed that the Dentist has opted out of the Medicare Program under §1128, 1156 or 1892 of the Social Security Act effective on the date the physician opted out until the physician cancels this opt-out agreement.

By signing this contract, Patient does the following:

1. Agrees not to submit a Medicare claim (or to request that the Dentist submit a claim) for services or items supplied by Dentist, even if they are otherwise covered under Medicare;
2. Accepts full responsibility for payment of the physician’s or practitioner’s charge for all services furnished by the physician or practitioner, unless any part of the service is covered under a private dental insurance plan;
3. Understands that Medicare limits do not apply to what the physician or practitioner may charge for items or services furnished by the physician or practitioner;
4. Understands that Medicare payment will not be made for any items or services furnished by the physician or practitioner that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim has been submitted;
5. Enters into this contract with the knowledge that he or she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare;
6. Acknowledges that a copy of this contract has been made available to him/her.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.