DR. MARK E. RANSCHAERT, D.M.D.DIPLOMATE, AMERICAN BOARD OF ORAL AND MAXILLOFACIAL SURGERY

321 NORTH PRESTON SUITE D · PROSPER, TX 75078TEL: 972.347.1800 · FAX: 972.347.1810

www.prosperoralsurgery.comAmerican Association of Oraland Maxillofacial Surgeons

Patient Information (Please Print)

Title: ________ First Name: ______________________________ MI: ____ Last Name___: ______________________________

Birthdate: ___________________________________Social Security: _______________________ Gender: Male Female

Address: ____________________________________________________ Apt./Suite: ____________________________________

City: ___________________________________________State: ________________________________ Zip:__________________

Phone: Home:(_____)_______- ___________________Work:(_____)_______- _____________ Ext: ________________________

Mobile:(____)_______- _____________________Fax:(_____)_______- ___________ Email: ________________________

Employer: __________________________________ Phone: (_____)_______- ___________Occupation: ____________________

Referred By:______________________________________________General Dentist: ____________________________________

Have you been seen in this practice before today? Yes No

Signature: ____________________________ Date: ____________(parent or guardian if patient is a minor)

Person Responsible for Account (if other than patient)

Title: ________ First Name: ______________________________ MI: ____ Last Name___: ______________________________

Relationship to Patient: Patient Spouse Child Other - Specify___________Social Security: _______________________

Address: ____________________________________________________ Apt./Suite: ____________________________________

City: ___________________________________________State: ________________________________ Zip:__________________

Phone: Home:(_____)_______- ___________________Work:(_____)_______- _____________ Ext: ________________________

Mobile:(____)_______- _____________________Fax:(_____)_______- ___________ Email: ________________________

Employer: __________________________________ Phone: (_____)_______- ___________Occupation: ____________________

Dental Insurance Information

Primary Insurance

Insur. Co._____________________________________

Group#:___________________Phone:______________

Employer:_____________________________________

Employee of other than patient

Name.________________________________________

Birthdate:________________Soc. Sec.:_____________

Subscriber#:_______________Sex: Male Female

Secondary Insurance

Insur. Co._____________________________________

Group#:___________________Phone:______________

Employer:_____________________________________

Employee of other than patient

Name.________________________________________

Birthdate:________________Soc. Sec.:_____________

Subscriber#:_______________Sex: Male Female

Signature: ____________________________ Date: ____________(of authorized representative of Prosper Oral Facial Surgery)

www.prosperoralsurgery.comAmerican Association of Oraland Maxillofacial Surgeons

PATIENT REGISTRATION FORM

I have hereby given Dr. Ranschaert consent to administer such anesthesia and medication, and to perform such surgical procedures, which are deemed necessary. I also consent to the release of information for insurance purposes and authorize the responsible third party pay directly to Dr. Ranschaert insurance benefits due me for services rendered. I also understand that I am responsible for any unpaid

balance due to Dr. Ranschaert.

Signature of Patient or Guardian: _____________________________________ Date:_________________________________________

Witness: _________________________________________________________Date:_________________________________________ ALL ACCOUNTS ARE IN FULL UNLESS PRIOR ARRANGEMENT HAS BEEN MADE

HEALTH HISTORY

Patient Name: ___________________________________ Patient Date of Birth: ___________________Age: ____________________ Height: _______ Weight: _______ Physician: ________________________________ Last Check-up___________________________

Please answer the following by circling Yes(Y) or No (N) for each individual question.

1. Are you in good health? Y N2. Have you been under a physician’s care during the past 2 years? Y NIf so, what for? ___________________________Date of last check up_________________Physician’s Name__________________________ Phone ___________________________3. Have you taken any kind of medicine or drugs during the past year? Y NPLEASE LIST ALL CURRENT MEDICATIONS HERE________________________________________________________________________________________________________________________________________________________________________4. Are you allergic to penicillin or any other drugs or medicine? Y N

PLEASE LIST ___________________________________________________________________________________________________________________________________________________________________________________________________________5. Have you ever had any excessive bleeding requiring special treatment? Y N6. Do you have sleep apnea? Y N7. Have you had any other surgery or serious illness? Y NPLEASE LIST________________________________________________________________________________________________8. Are you wearing a removable denture? Y N9. Are you wearing contact lenses? Y N10. Have you ever had a problem with general anesthesia? Y N11. Do you take bisphosphonates/calcium replacements?(Fosamax, Aredia, Didronel, Actonel, Boniva, Zometa, etc) Y N12. Are you allergic to latex? Y N13. Do you use alcohol? How much per day? __________ Y N14. Do you smoke? For how long? Y N15. Are you, or have you been in a drug or alcohol recovery program? Y N16. (Women) Are you pregnant, trying to become pregnant or any chance you may be pregnant? Y N17. (Women) Do you take birth control pills? Y N18. (Women) Are you breast feeding? Y N19. Do you have any other disease, condition or problem not listed above that the doctor shouldknow about?

Health History continued . . .

www.prosperoralsurgery.comAmerican Association of Oraland Maxillofacial Surgeons

HEALTH HISTORY

Circle any of the following that apply to you:

Heart Disease COPD Tuberculosis Stroke

Congenital Heart Disease Asthma Hepatitis Epilepsy

Artificial Valves Previous Endocarditis Jaundice Sinus Problems

Psychiatric treatment High blood pressure Diabetes Arthritis

Anemia Cataract Surgery Immuno-deficiency Joint Replacement

Heart surgery Pacemaker Radiation Treatment Leaky Valve

Liver Disease Emphysema Blood Thinners Heart Palpitations

Chest Pain Heart Attack Heart Trouble Shortness of Breath

Seizures Lupus Fainting Dizziness

Kidney Disease Angina Chronic Cough Bronchitis

Osteoporosis Bleeding Disorder Heart Murmur Rheumatic Heart Disease

Neck Problems Thyroid Disease Anxiety Organ Transplant

I understand the importance of a truthful and complete Health History and realize that incomplete information may have an adverse effect on my treatment. To the best of my knowledge, the information above is complete and accurate.

Patient or Guardian: _____________________________________________________ Date: _____________________________

Witness: ________________________________________________________________ Date: ____________________________

  

 

NOTICE OF PRIVACY PRACTICES 

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW 

YOU CAN GET ACCESS TO THIS INFORMATION 

PLEASE REVIEW IT CAREFULLY, THE PRIVACY OF YOU HEALTH INFORMATION IS IMPORTANT TO US 

OUR LEGAL DUTY 

We are required by applicable federal and state law to maintain the privacy of your health information.  We are also required to give you this 

Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices 

that are described in this Notice while it is in effect. This Notice takes effect (04/14/03), and will remain in effect until we replace it. 

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by 

applicable law. We reserve the right to make the changes in our practices and the new terms of our Notice effective for all health information 

that we maintain, including health information we created or received before we made the changes. Before we make significant changes in our 

privacy practices, we will change this Notice and make the new Notice available upon request. You may request a copy of our Notice at any 

time. For more information about our privacy practices, or for additional copies of this Notice, please contact u using the information listed at 

the end of this Notice. 

USES AND DISCLOSURES OF HEALTH INFORMATION 

We use and disclose health information about you for treatment, payment and healthcare operations. For example: Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you. Payment: We may use and disclose your health information to obtain payment for services we provide to you. Healthcare Operations: We may use and disclosed your health information in connection with our healthcare professionals, evaluating include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certifications, licensing or credentialing activates.  Your Authorization: In Addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclose your health information for any reason except those described in this Notice.  To Your Family and Friends: We must disclose your health information to you , as described in the patient Right section of this Notice . We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.  Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locations) a family member, your personal representative or another person responsible for  your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of  your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x‐rays, or other similar forms of health information.  Marketing Health‐Related Services: We will not use your health information for marketing communications without your written authorization.    

  Required by Law:  We may use or disclose your health information when we are required to do so by law.   Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.        

  

 

  National Security: We may disclose to military authorities the health of Armed Forces personnel under certain circumstances. We may disclose to authorize federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institutions or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.  Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letter).  PATIENT RIGHTS  Access: you have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice.  We will charge you a reasonable cost‐based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $0.50 for each page, $15.00 Per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost‐based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure).  Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activates, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12‐month period, we may charge you reasonable, cost‐based fee for responding to these additional requests. Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).  Alternative communications: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. {You must make your request in writing}. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.  Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended). We may deny your request under certain circumstances.  Electronic Notice: if you receive this Notice on our Web site or by electronic mail (e‐mail), you are entitled to receive this Notice in written form also.  QUESTIONS AND COMPLAINTS  If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services.  We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.  Contact Officer: Shannon Bennefeld Telephone: (972)914‐1800 E‐mail Address: 321 N. Preston Rd. ste, D Prosper, TX 75078   

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

The law requires that the staff at Prosper Oral & Facial Surgery make every effort to inform you of your rights related to your personal health information.

_____ I have read (or given the opportunity to read) Prosper Oral & Facial Surgery’s Notice of Privacy Practices and agree to continue my care with Prosper Oral & Facial Surgery under said terms.

List below the name of the person(s) to whom we may give information regarding your condition, treatment, diagnosis, or financial responsibility.

Spouse: ______________________________ Parent:___________________________________

Son/Daughter: ______________________Other:______________________________________

Initial here ____________if you wish that your information not be disclosed to anyone

List any specific person who should not have this information:___________________________

List the number(s) where we may reach you and circle the primary: ______________________________________________________________________________

May we leave a detailed voicemail message on these numbers? _________Yes _________No

Knowing that standard email communication may not be totally secure, I still consent, if requested, to communications from my doctor or staff through my standard email. __________Yes __________No

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. I hereby authorize Prosper Oral & Facial Surgery to release all information required to determine benefits and process any insurance claims to secure payment. I also authorize my insurance benefits be paid directly to the doctor, and I understand I am financially responsible for all unpaid charges not covered by my insurance. If needed, I authorize the use of this signature on all insurance claim submissions.

____________________________________________________ __________________________ Patient Date

If you are signing as a personal representative of the patient, please indicate your relationship

__________________________________________________ __________________________ Representative Relationship to Patient

Medicare Private Contract

By signing this contact I understand and agree that I will not submit (or request that my oral and maxillofacial surgeon submit) a claim to Medicare or its agents for services provided by Mark E. Ranschaert MDM even if such services would otherwise be covered. I agree to be fully responsible, through insurance or otherwise, for payments of services by Mark E. Ranschaert MDM understand that no claims will be submitted to Medicare and no Medicare reimbursement will be provided for these services. I understand that there are no limits specified by Medicare as to the amounts that may be charged by the oral and maxillofacial surgeon for services provided. I understand that Medicare plans do not, and other health and medical care insurance plans may elect not to, make payments for such services. I understand and have the right to have services provided by other oral and maxillofacial surgeons or other practitioners for who Medicare payments would be made, and that I am not compelled to enter into private contracts that apply to covered care furnished by other health care professionals who have not opted-out. I understand that Mark E. Ranschaert is excluded from participation in the Medicare program under Section 1128 of the Social Security Act or pursuant to any other legal authority. Patient’s Signature:______________________________________________________ Oral and Maxillofacial Surgeon’s Signature:_______________________________________________________

Our Financial Policy BASIC POLICY: PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED. Our office accepts the following forms of payment: Visa, MasterCard, American Express, Cash, Care Credit, or Personal Checks. A valid ID must be presented and copied at the time of initial consultation. It is our policy to submit an insufficient fund (NSF Checks) to an outside collection agency that will electronically obtain any payments due to our office, and a $25.00 NSF Check Fee will be charged to your account. Additionally, if account payment has not been made to your account, within 60 days of our office requesting payment, your balance will automatically be placed on a financed plan, with interest. If no contact or appropriate arrangements have been made with our office; within 90 days of our office requesting payment, the account will be referred to the necessary collection parties and a collection fee of $500 will be assessed, with interest. INSURED PATIENTS: As a service and courtesy to our patients, we will file your primary insurance. This courtesy does not relieve the patient of financial responsibility, nor suspend payments until the insurance company has paid the claim. Every effort will be made to estimate your co-payments and deductibles, with assistance from your insurance company. The insurance company does not guarantee payment during the verification process. The charges for services rendered, by this office; are the responsibility of the patient or patient guarantor. Co-Payment and deductible fees are due at the time of service. Please understand that the insurance policy is a contract between you and your insurance company. If an insurance company has not paid within 365 days of billing, and unpaid professional and clinical fees are due and payable in full from you, to our office. Please be advised to follow up with your insurance company to verify they are processing your claim. In addition, some services offered may not be covered by your insurance policy. By presenting for care, you agree to be responsible for all services and charges, regardless of your insurance status. Should any provided services not be covered by your insurance, you are to cover the charge. In addition, you are responsible for any remaining balance. We are IN-NETWORK with the following DENTAL Plans: AETNA, BCBS, CIGNA, DELTA DENTAL, DELTAL SELECT, HUMANA, METLIFE and UNITED HEALTHCARE. We are OUT-NETWORK with ALL MEDICAL Plans UNINSURED PATIENTS: Our fees will be due and payable at the time services are rendered. NON-COVERED SERVICES: Any charges not paid by your insurance company will require payment in full at the time services are provided, or upon notice of insurance claim denial. PERSONAL INJURY CASES: This office does not accept liens or bills for auto accident, liability, or lawsuit-related cases. It is the patient’s responsibility and obligation to pay at the time services are rendered. FOLLOW-UP/AFTER HOUR VISITS: Periodic post-operative office visits may not be covered by your insurance policy, but may be required by your treating provider. Additional fees may apply. CANCELLATION of APPOINTMENTS: Our goal is to provide high quality care at a low cost to our patients, and in fairness to other patients and providers; we require a 24 hour notice when cancelling an appointment. There is a fee for visits not cancelled within this timeframe. This office reserves the right to dismiss patients with excessive cancelled appointments. FOR DENTAL IMPLANT PORCEDURES: We request payment in full two (2) weeks prior to each planned procedure date. ASSIGNMENT of INSURANCE BENEFITS for INSURED PATIENTS: I hereby assign all medical and/or surgical benefits, including major medical benefits to which I am entitled, private insurance and any other health plans to <practice name> This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is considered to be as valid as the original. I understand that I am financially responsible for all charges whether or not they are paid by my insurance company. I hereby authorize and said assignee to release all information necessary to secure the payment. GUARANTOR/PATIENT SIGNATURE: ________________________________ DATE: __________________ I HAVE READ, UNDERSTOOD, AND AGREE TO THE ABOVE FINANCIAL POLICY FOR PAYMENT OF THE RENDERED FEES. I UNDERSTAND THAT I AM ULTIMATELY RESPONSIBLE FOR ALL FEES FOR SERVICES PROVIDED TO ME. WITNESS SIGNATURE: ________________________________ __________DATE: __________________