15 E. Euclid Avenue, Haddonfield, NJ 08033 (856) 795-4600
449 Hurffville-Crosskeys Road, Unit II, Sewell, NJ 08080 (856) 582-4222
1630 Route 322, Suite A, Woolwich, NJ 08085 (856) 832-4690
www.lanziburkeoralsurgery.com
TO OUR NEW PATIENTS
Thank you for selecting Lanzi│Burke Oral & Maxillofacial Surgeons as your healthcare
provider. Prior to your initial visit with our staff, we ask that you complete the “Patient
Information” form and the “Patient Medical History” form and bring these completed forms to
our office at the time of your scheduled appointment. This will help to facilitate your new
patient registration.
A copy of our Financial Policy is included; we ask that you read and sign this policy and
bring the signed copy with you to our office. If you are not clear as to what your financial
responsibility will be for your exam and/or surgery visit, please call your insurance carriers to
find out about your coverage. If you arrive at our office for your appointment and need our
assistance to investigate your coverage, this will delay our proceeding with your scheduled
appointment and could result in having to reschedule your appointment. Your insurance
company makes the final determination as to what your financial responsibility will be and
you will be billed for any services not covered in full by your insurance. Please advise the
front desk upon your arrival if your financial responsibility needs to be determined before
proceeding with your appointment.
Please bring your medical and dental insurance cards with you as well, as we will need to
make copies of this information for your file. If you have a HMO-type insurance, you will
need to obtain a referral from your Primary Care Physician prior to your visit. Please call
our Haddonfield office at (856) 795-4600, our Washington Twp. office at (856) 582-4222 or our
Woolwich Twp. office at (856) 832-4690 if you need to determine if we are participating with
your particular medical or dental plans or with any questions or concerns. Again, we
recommend that you call your insurance carriers prior to your visit to understand your coverage
and the insurance carrier’s requirements.
For patients who are covered by PIP insurance (motor vehicle accident-related insurance),
please bring to our office the motor vehicle insurance information including date and
circumstances of the accident, your claim number, your adjustor’s name and telephone number
and the address as to where we are to mail claims. Your insurance company should send you an
“Assignment of Benefits” form which you need to complete and bring to our office on your
initial visit.
We look forward to serving your needs and remember to bring these completed forms with you
to your appointment along with your insurance card(s) and referral (if necessary.) An
Appointment Checklist is provided on the reverse side of this form for your convenience.
(See other side)
Guy L. Lanzi, D.M.D Jonathan E. Burke, D.M.D
Elizabeth A. Wagner, D.M.D Nathan J. Spencer, D.D.S
Please Print Clearly and Complete All Sections
PATIENT INFORMATION
 Male
 Female
Patient Name: _______________________________________________
Birth Date: _________ Age: ____
Last
First
Initial
Social Security: ___________________ Telephone #: Home: (____)______________ Cell #: (
) _________________
Email Address: _____________________________ Marital Status:
S
M
Sep
D
W
Address: ________________________________________ City: ______________________ State: ___ Zip Code: _________
Patient’s Employer: _______________________________________________ Telephone#: (____)_____________ Ext:_____
Employer Address: ________________________________ City: ______________________ State: ___ Zip Code: ________
GUARANTOR INFORMATION
Primary Guarantor Name: ____________________________________________________ Birth Date: __________________
Last
First
Initial
Social Security: ___________________ Telephone #: Home (____)_________________ Relation to Patient: _____________
Address: ________________________________________ City: _____________________ State: ____ Zip Code: ________
Guarantor’s Employer: ____________________________________________ Telephone#: (____)____________ Ext: ______
Employer’s Address: _______________________________ City: _____________________ State: ____ Zip Code: ________
Secondary Guarantor Name: ___________________________________________________ Birth Date:_________________
Last
First
Initial
Social Security: ___________________ Telephone #: Home (____)_________________ Relation to Patient: _____________
Address: ________________________________________ City: _____________________ State: ____ Zip Code: ________
Guarantor’s Employer: ____________________________________________ Telephone#: (____)____________ Ext: ______
Employer’s Address: _______________________________ City: _____________________ State: ____ Zip Code: ________
INSURANCE INFORMATION
Primary Medical Insurance: ___________________________________________
Claims Office Address: _______________________________
Telephone #: (____)_________________
City: ___________________ State: ____ Zip Code: ______
Subscriber Name: _________________________________ Policy/ID #: _____________________ Group #: ______________
Primary Dental Insurance: ____________________________________________
Claims Office Address: _______________________________
Telephone #: (____)_________________
City: ___________________ State: ____ Zip Code: ______
Subscriber Name: _________________________________ Policy/ID #: _____________________ Group #: ______________
Secondary Medical Insurance: _________________________________________
Claims Office Address: _______________________________
Telephone #: (___)_________________
City: ___________________ State: ____ Zip Code: ______
Subscriber Name: _________________________________ Policy/ID #: _____________________ Group #: ______________
Secondary Dental Insurance: __________________________________________
Claims Office Address: _______________________________
Telephone #: ____)_________________
City: ___________________ State: ____ Zip Code: ______
Subscriber Name: _________________________________ Policy/ID #: _____________________ Group #: ______________
WORKERS COMPENSATION OR OTHER LIABILITY CLAIMS
Date of Accident: ________________
Claim #: ____________________________ Policy #: __________________________
Supervisor’s Name: ____________________________________
Telephone #: (____)________________________________
Insurance Company: _____________________________________________________________________________________
Claims Office Address: ___________________________________________________________________________________
City: _________________________________________________
Claim Manager’s Telephone: (____)_______________
State: _____________
Are we on your Employer’s Panel?
Zip Code: _________________
Yes ___
No ___ Not Sure ___
AUTO ACCIDENT CLAIMS
Date of Accident: _________________
Claim #: __________________________ Policy #: ___________________________
Insurance Company: _________________________________________
Telephone #: (____)_________________________
Claims Office Address: ____________________________________________________________________________________
City: _________________________________________________
State: _____________
Adjuster’s Name: ____________________________________________
Zip Code: ________________
Telephone #: (____)_________________________
Name of Insured: ________________________________________________________________________________________
MVA Details: Auto vs. Auto _____
Driver _____
Auto vs. Truck _____
Auto vs. Pole _____
Auto vs. Other (Specify) _____________
Passenger _____
AUTHORIZATIONS
I authorize any holder of medical/dental or other information about me to release this information to my insurance company, its
intermediaries or carriers to my attorney or another physician’s office. I hereby authorize direct payment of medical/dental and/or
surgical, benefits, to include major medical benefits to which I am entitled, Medicare, private insurance, and any other health plans
to Lanzi/Burke Associates and any of its affiliated practices.
I also permit a copy of this authorization to be used in place of the original. This assignment will remain in effect until revoked by
me in writing. I understand that, as these services were performed for me or my legal dependent, I am financially
responsible for all charges whether or not paid by insurance.
Signature of patient or responsible party: _______________________________________________ Date: ________________
I consent to be photographed before, during and/or after the treatment; that these photographs shall be the property of
Lanzi/Burke Associates, and may be published in scientific journals and/or shown for scientific reasons.
Signature of patient or responsible party: _______________________________________________ Date: _________________
MEDICARE PATIENTS
I request that payment of authorized Medicare/Medigap benefits be made to me or on my behalf to Lanzi/Burke Associates and
any of its affiliated practices for any services furnished to me by Lanzi/Burke Associates and any of its affiliated practices.
I authorize any holder of medical or other information about me to release to the Health Care Financing Administration and its
agents any information needed to determine these benefits for related services.
Medicare Beneficiary Signature
Updated 1/26/07
Date
Please Print Clearly and Complete All Sections
PATIENT MEDICAL HISTORY
Patient Name: ____________________________________________
Date: ____________________
Please circle Y (yes) or N (no) if you (patient) have ever had any of the following:
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Adrenal Gland
disorder
Arthritis
Asthma
Blood disorders/
prolonged bleeding
Chemotherapy
Diabetes
Drug abuse
Epilepsy/seizures
Glaucoma
Weight: _____
Height: _____
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Heart disease
Heart murmur/(MVP)
Heart valve or joint
replacement
Hepatitis/liver disease
High blood pressure
Infectious disease/AIDS
Kidney disease
Latex sensitivity
Lung disease
Penicillin allergy
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Psychiatric disorder
Radiation
Rheumatic Fever
Snoring
Stroke
Thyroid problems
TMJ problems
Ulcers
Osteoporosis
Taking blood thinners
Do You Smoke? YES _____ How much? ________ NO _____
List any food and/or medication allergies:
List any medications/herbs/dosages you are presently taking:
:
List any other medical problems not listed above
Have you had any general anesthesia? YES _____ If yes, list below NO _____
***SIGNATURE(S) REQUIRED ON REVERSE OF THIS FORM***
FOR WOMEN ONLY
Are you pregnant? YES _____ # of months _____ NO _____
Is there a possibility you might be pregnant? YES _____ NO _____
Are you trying to become pregnant? YES _____ NO _____
Do you wish to consult with a physician to rule out pregnancy? YES _____ NO _____
I understand that surgery or anesthesia during early stage of pregnancy could potentially harm a fetus.
Patient Signature:_____________________________________________ Date:__________________
Are you nursing? YES _____ NO _____
Are you taking birth control pills? YES _____ Name of pill: _________________________ NO _____
You may be prescribed an antibiotic and/or other medications that interfere with the effectiveness of oral contraceptives.
Therefore, I understand that I need to consult with my physician regarding the effects of any antibiotics and/or other medications
prescribed for me to determine if an additional form of birth control will be necessary to prevent unplanned pregnancy.
Patient Signature: _____________________________________________ Date: _________________
PHYSICIAN INFORMATION
General Dentist/
Orthodontist: ___________________________
Medical Doctor: _________________________
Address: ______________________________
Address: ______________________________
City/State/Zip Code: _____________________
City/State/Zip Code: _____________________
Telephone #: (____) _____________________
Telephone #: (_____) ____________________
Pharmacy: ________________________________
Address: __________________________________
City/State/Zip Code: _________________________
Telephone #: (_____) ________________________
REFERRAL SOURCE: Newspaper (which one?)_______________________ Internet ____________
Referring Physician________________ Friend/Former Patient_______________ Insurance Company_______
PERSON TO CONTACT IN CASE OF EMERGENCY
Name: ____________________________________________
Last
First
Initial
Telephone # :(_____) _____________________
Relationship: ______________
Address: ____________________________________ City: _____ State: ____ Zip Code: _______
Employer: _____________________________________ Work Telephone #: (____) _______________
PATIENT MEDICAL INFORMATION CONSENT
I UNDERSTAND THAT THE INFORMATION PROVIDED ON THIS MEDICAL HISTORY FORM IS ACCURATE TO
THE BEST OF MY KNOWLEDGE. I WILL NOTIFY THE DOCTOR OF ANY CHANGES IN MY HEALTH OR
MEDICATION. I ACCEPT FULL RESPONSIBILITY/LIABILITY FOR ANY CONSEQUENCES OF PROVIDING FALSE
OR MISLEADING INFORMATION.
PATIENT/GUARDIAN SIGNATURE: _____________________________________ DATE: __________________
WITNESS TO SIGNATURE: ____________________________________________ DATE: ___________________
Guy L. Lanzi, D.M.D
Elizabeth A. Wagner, D.M.D
Jonathan E. Burke, D.M.D
Nathan J. Spencer, D.D.S
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION
PLEASE READ IT CAREFULLY
The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) is a Federal
program that requests that all medical records and other individually identifiable health
information used or disclosed by us in any form, whether electronically, on paper, or orally are
kept properly confidential. This Act gives you, the patient, the right to understand and control
how your personal health information (“PHI”) is used. HIPAA provides penalties for covered
entities that misuse personal health information.
As required by HIPAA, we prepared this explanation of how we are to maintain the
privacy of your health information and how we may disclose your personal information.
We may use and disclose your medical records only for each of the following purposes:
treatment, payment, and health care operation.

Treatment means providing, coordinating, or managing health care and related services
by one or more healthcare providers. An example of this would include referring you to
a retina specialist.

Payment means such activities as obtaining reimbursement for services, confirming
coverage, billing or collections activities, and utilization review. An example of this
would include sending your insurance company a bill for your visit and/or verifying
coverage prior to a surgery.

Health Care operations include business aspects of running our practice, such as
conducting quality assessments and improving activities, auditing functions, cost
management analysis, and customer service. An example of this would be new patient
survey cards.

The practice may also disclose your PHI for law enforcement and other legitimate
reasons although we shall do our best to assure its continued confidentiality to the extent
possible.
We may also create and distribute de-identified health information by removing all reference
to individually identifiable information.
We may contact you, by phone or in writing, to provide appointment reminders or
information about treatment alternatives or other health-related benefits and services, in addition
to other fundraising communications, that may be of best interest to you. You do have the right
to “opt out” with respect to receiving fundraising communications from us.
The following use and disclosures of PHI will only be made pursuant to us receiving a
written authorization from you:




Most uses and disclosure of psychotherapy notes;
Uses and disclosure of your PHI for marketing purposes, including subsidized treatment
and health care operations;
Disclosures that constitute a sale of PHI under HIPAA; and
Other uses and disclosures not described in this notice.
You may revoke such authorization in writing and we are required to honor and abide by that
written request, except to the extent that we have already taken actions relying on your
authorization.
You may have the following rights with respect to your PHI:







The right to request restrictions on certain uses and disclosures of PHI, including those
related to disclosures of family members, other relatives, close personal friends, or any
other person identified by you. We are, however, not required to honor a request
restriction except in limited circumstances which we shall explain if you ask. If we do
agree to the restriction, we must abide by it unless you agree in writing to remove it.
The right to reasonable requests to receive confidential communications of Protected
Health Information by alternative means or at alternative locations.
The right to inspect and copy your PHI.
The right to amend your PHI.
The right to receive an accounting of disclosures of your PHI.
The right to obtain a paper copy of this notice from us upon request.
The right to be advised if your unprotected PHI is intentionally or unintentionally
disclosed.
If you have paid for services “out of pocket”, in full, and you request that we do not disclose
PHI related solely to those services to a health plan, we will accommodate your request, except
where we are required by law to make a disclosure.
We are required by law to maintain the privacy of your Protected Health Information and to
provide you the notice of our legal duties and our privacy practice with respect to PHI.
This notice is effective as of September 19, 2013 and it is our intention to abide by the terms
of the Notice of Privacy Practices and HIPAA regulations currently in effect. We reserve the
right to change the terms of our Notice of Privacy Practice and to make the new notice provision
effective for all PHI that we maintain. We will post and you may request a written copy of the
revised Notice of Privacy Practice from our office.
You have recourse if you feel that your protections have been violated by our office. You
have the right to file a formal, written complaint with office and with the Department of Health
and Human Services, Office of Civil Rights. We will not retaliate against you for filing a
complaint.
Feel free to contact the Practice Compliance Officer for more information, in person or in
writing.
Guy L. Lanzi, D.M.D Jonathan E. Burke, D.M.D
Elizabeth A. Wagner, D.M.D Nathan J. Spencer, D.D.S
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
By signing below, you indicate that Lanzi Burke & Associates has provided the Notice of Privacy
Practices to you on:
___________________________
Patient’s Signature
______________
Date
___________________________
Print Name
______________________________
Authorized Representative Signature
___________________
Relationship to patient
_____________
Date
_______________________________
Print Name
Request for Authorization of Protected Health Information
A. Family and Friends. It is the office policy of Lanzi/Burke and Associates, LLC not to
release confidential medical information regarding your treatment to family members or
friends, except for (i) parent/legal guardian, (ii) other persons authorized by the patient,
(iii) as we may reasonably infer from the circumstances (for example, if you bring a
family member or friend into the exam room, we will assume, unless you object, that the
person is entitled to receive information regarding your treatment), (iv) in emergency
situations, or (v) other as otherwise permitted by the Health Insurance Portability and
Accountability Act of 1996 (HIPAA).
If you anticipate that you will need or want your medical information to be provided to
family members, friends, or caretakers/babysitters, please indicate that below, so that we
may best serve you. If you do not want any of your medical information provided to a
family member, please check (√) the line next to the “no” response. By signing below,
you authorize the following people to receive information regarding your treatment or
care. (If you wish to add names later on, please confirm this in writing, or call our staff.)
Spouse: _________________________
Parent: __________________________
Other:___________________________
___________________________
___________________________
_______ yes
_______ yes
_______ yes
_______ yes
_______ yes
_______ no
_______ no
_______ no
_______ no
_______ no
B. Alternative Communications. You are also entitled to specify alternative, reasonable
means of communication, if you do not wish to be contacted by us in a certain way.
I hereby request the following means of contact only:
_______________________________________________________________________
_______________________________________________________________________
PRINTED NAME _______________________________________________________
Patient/Parent/Guardian Signature: ___________________________________________
Date: ________________________
________________________________________________
FOR OFFICE USE
Changes to above, authorized by patient over the phone:
Change
Date
_____________________________
_________
_____________________________
_________
_____________________________
_________
F:\Documents/Forms
Staff Initials
__________
__________
__________
New Jersey Department of Banking and Insurance
CONSENT TO REPRESENTATION IN APPEALS OF UTILIZATION MANAGEMENT
DETERMINATIONS AND AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
IN UM APPEALS AND INDEPENDENT ARBITRATION OF CLAIMS
APPEALS OF UTILIZATION MANAGEMENT DETERMINATIONS
You have the right to ask your insurer, HMO or other company providing your health benefits (carrier) to change its
utilization management (UM) decision if the carrier determines that a service or treatment covered under your health
benefits plan is or was not medically necessary. 1 This is called a UM appeal. You also have the right to allow a doctor,
hospital or other health care provider to make a UM appeal for you.
There are three appeal stages if you are covered under a health benefits plan issued in New Jersey. Stage 1: the carrier
reviews your case using a different health care professional from the one who first reviewed your case. Stage 2: the
carrier reviews your case using a panel that includes medical professionals trained in cases like yours. Stage 3: your
case will be reviewed through the Independent Health Care Appeals Program of the New Jersey Department of Banking
and Insurance (DOBI) using an Independent Utilization Review Organization (IURO) that contracts with medical
professionals whose practices include cases like yours. The health care provider is required to attempt to send you a
letter telling you it intends to file an appeal before filing at each stage.
At Stage 3, the health care provider will share your personal and medical information with DOBI, the IURO, and the
IURO’s contracted medical professionals. Everyone is required by law to keep your information confidential. DOBI must
report data about IURO decisions, but no personal information is ever included in these reports.
You have the right to cancel (revoke) your consent at any time. Your financial obligation, IF ANY, does not change
because you choose to give consent to representation, or later revoke your consent. Your consent to representation and
release of information for appeal of a UM determination will end 24 months after the date you sign the consent.
INDEPENDENT ARBITRATION OF CLAIMS
Your health care provider has the right to take certain claims to an independent claims arbitration process through the
DOBI. To arbitrate the claim(s), the health care provider may share some of your personal and medical information with
the DOBI, the arbitration organization, and the arbitration professional(s). Everyone is required to keep your information
confidential. The DOBI reports data about the arbitration outcomes, but no personal information will be in the reports.
Your consent to the release of information for the arbitration process will end 24 months after the date you sign the
consent.
CONSENT TO REPRESENTATION IN UM APPEALS AND AUTHORIZATION TO RELEASE OF INFORMATION IN UM
APPEALS AND ARBITRATION OF CLAIMS
PRINT NAME
I,
, by marking √ (or x ) and signing below, agree to:
representation by Lanzi Burke & Associates LLC in an appeal of an adverse UM determination as allowed by
N.J.S.A. 26:2S-11, and release of personal health information to DOBI, its contractors for the Independent Health
Care Appeals Program, and independent contractors reviewing the appeal. My consent to representation and
authorization of release of information expires in 24 months, but I may revoke both sooner.
release of personal health information to DOBI, its contractors for the Independent Claims Arbitration Program, and
any independent contractors that may be required to perform the arbitration process. My authorization of release of
information for purposes of claims arbitration will expire in 24 months.
Signature: ___________________________________________
___________
Ins. ID#:______________
Date:
1
If the patient is a minor, or unable to read and complete this form due to mental or physical incapacity, a personal representative of the patient may
complete the form.
Health Care Provider: The Patient or his or her Personal Representative MUST receive a copy of both
sides/pages of this document AFTER PAGE 1 has been completed, signed and dated.
dobiihcaparb 07/06
Page 1 of 3
Relationship to Patient:
back)
I am the Patient
I am the Personal Representative (provide contact information on
New Jersey Department of Banking and Insurance
NOTICE OF REVOCATION OF CONSENT TO REPRESENTATION IN APPEALS OF
UTILIZATION MANAGEMENT DETERMINATIONS AND OF AUTHORIZATION TO
RELEASE OF MEDICAL RECORDS
You may, at any time, revoke the consent you gave allowing a health care provider to represent you in an appeal of a UM
determination and allowing the release of your medical records to the DOBI, the IURO and medical professionals that
contract with the IURO. You may use this form to revoke your consent, or you may submit some other written evidence of
your intent to revoke consent, if you prefer. Either way, if you have not yet received a Stage 2 UM determination from the
carrier, send the written and signed revocation to the carrier at the address indicated in the carrier’s written notice to you
regarding the carrier’s initial UM determination. If you have received a Stage 2 UM determination, then your revocation
should be sent to:
New Jersey Department of Banking and Insurance
Consumer Protection Services
Office of Managed Care – Attn: IHCAP
P.O. Box 329
Trenton, NJ 08625-0329
OR for courier service to: 20 West State Street
OR by fax to: (609) 633-0807
You may also want to send a copy of your notice of revocation to the health care provider.
ONLY COMPLETE AND SEND THIS IN WHEN AND IF YOU WISH TO REVOKE YOUR CONSENT!
REVOCATION OF CONSENT TO REPRESENTATION AND RELEASE OF MEDICAL RECORDS IN UM
DETERMINATION APPEALS
I hereby revoke my consent to representation by Lanzi Burke & Associates LLC and my authorization to the release
of medical information in an appeal of an adverse UM determination. I understand that by revoking consent, the
UM appeal may not be pursued further by my health care provider. I understand that this revocation may occur
after my personal and medical information has already been shared with the DOBI, the IUROs and medical
professionals with whom the IUROs contract, but that no further distribution of records in this matter will occur
based on my authorization, and that all of my medical and personal information is required to be maintained as
confidential by all parties.
Signature:
Relationship to Patient:
I am the Patient
Ins. ID#______________
I am the Personal Representative
Date:______________
Contact Information of Personal Representative
Please provide the following contact information IF it is different from the patient’s contact information:
PRINT NAME: _____________________________________________________________
ADDRESS:_______________________________________________________________________________________
__
Health Care Provider: The Patient or his or her Personal Representative MUST receive a copy of both
sides/pages of this document AFTER PAGE 1 has been completed, signed and dated.
dobiihcaparb 07/06
Page 2 of 3
__________________________________________________________________________________________
PHONE: _______________ FAX: _______________ EMAIL:
________________________________
Health Care Provider: The Patient or his or her Personal Representative MUST receive a copy of both
sides/pages of this document AFTER PAGE 1 has been completed, signed and dated.
dobiihcaparb 07/06
Page 3 of 3
LANZI/BURKE ORAL & MAXILLOFACIAL SURGEONS
FINANCIAL POLICY
We welcome you to our oral surgery practice. We are committed to provide you with the best
care possible and appreciate your decision to choose our practice. We are happy to discuss your
questions or concerns pertaining to your medical/dental care or about our billing procedures.
If you do not have medical and/or dental insurance, payment for services rendered is required on
the day of your visit. You may pay by cash, check, Visa, MasterCard, MAC Debit, Discover,
American Express or Care Credit.
If you have medical and/or dental insurance, we will submit your claims for payment as a
courtesy. However, in order for our billing department to do this, you must bring in your
insurance card(s) at the time of your visit. You must notify our front desk personnel if your
insurance coverage changes at any time during the course of your treatment. If we can estimate
how much of your bill is not going to be covered by insurance such as co-pays, deductibles, or
percentage, we will require this amount to be paid at the time of the visit.
PLEASE NOTE: WE CAN ONLY ESTIMATE THE AMOUNT YOUR INSURANCE
CARRIER MAY PAY TOWARDS YOUR SERVICES. FINAL DETERMINATION IS
MADE BY THE INSURANCE CARRIER AND WE WILL BILL YOU FOR ANY
REMAINING BALANCE AFTER THEY HAVE PAID! We strongly recommend that you
also call your insurance carriers to check your benefits and we can assist you with any
information required.
Medicare Patients:
Our doctors are participating providers with the Medicare Program.
However, Section 2336 of the Medicare Carrier Intermediary Manual states that “items and
services in connection with the care, treatment, filling, removal or replacement of teeth or
structures directly supporting the teeth are not covered. Administration of anesthesia, diagnostic
x-rays and other related procedures are not covered unless the primary procedure being
performed by the oral surgeon is covered.
HMO Patients: If you have an HMO-type insurance, you must go to a “participating provider”
in your plan to access your coverage. You are required to obtain a referral from your Primary
Care Physician prior to your visit. You should also check with your insurer to determine if
preauthorization is required for elective surgical procedures that you are scheduling with our
office.
PPO, Point of Service and Managed Care Patients: In order to obtain the highest level of
coverage with these types of plans, you must choose an “in-network provider”. With the
managed care and point of service plans, you must obtain a referral from your Primary Care
Physician as well. Please check with your individual plan to obtain necessary information
regarding referrals, in-network providers and pre-authorization requirements.
You will be held responsible for any balance remaining after our insurance billing cycle is
complete. Please do not simply ignore our statements. Patient shall reimburse the practice for all
expenses incurred in collection of monies due and owing, including, without limitation,
reasonable attorney’s fees and expenses equal to at least 25% of the total amount sought to be
recovered.
If you receive a bill that you question, please call our office at Haddonfield (856) 795-4600
Sewell (856) 582-4222 Woolwich (856) 832-4690 (Revised 01/16)
Patient/Guarantor’s
signature:___________________________________________Date:______________________________
Guy L. Lanzi D.M.D Jonathan E. Burke D.M.D
Elizabeth A. Wagner D.M.D Nathan J. Spencer D.D.S
CONSENT FOR EXAMINATION
I consent to the taking of necessary x-ray(s), impressions (if necessary) for examination, diagnosis and surgical treatment.
______________________________________
______________________________
PATIENT (PARENT OR GUARDIAN IF MINOR)
WITNESS TO SIGNATURE – DATE
******************************************************************************************************************************************
******************************************************************************************************************************************
CONSENT FOR ANESTHESIA AND SURGERY
I give consent for the administration of a local anesthetic, nitrous oxide (sweet air), intravenous sedation and/or general anesthesia as
recommended by the doctor and approved by me.
I understand that all anesthetics are drugs and that side effects and reactions are possible.
I certify that I have not had anything to eat or drink for at least eight (8) hours before receiving intravenous sedation or general
anesthesia. I understand that serious consequences may result if this rule is not observed.
I give consent for the following surgical procedure(s):
I understand that the surgery may require an incision of soft tissue or bone, and wound closure with sutures. This may be followed by
discomfort and swelling requiring several days of recuperation.
I consent to a bone grafting procedure to be done with bone products including those from human or animal sources in conjunction with
the procedure if indicated.
I consent to the taking of necessary x-ray(s) for examination, diagnosis and surgical treatment.
Complications of surgery are possible, but not probable. The possibilities vary with the particular procedure. They may include, but are
not limited to the following:
1.) Postoperative bleeding
2.) Injury to adjacent teeth and fillings
3.) Postoperative infection
4.) Small root fragments may be purposefully
left in jaw if their removal requires extensive
surgery or may result in possible injury to
vital structures
5.) Fracture of the jaw bone
6.) Discoloration (black and blue) of face
and/or jaw
7.) Soreness at corners of mouth and/or lips
8.) Numbness, pain, or changed feelings in the teeth, gums, lip,
chin and/or tongue (including possible loss of taste). This is due
to the closeness of tooth roots (mainly with wisdom teeth) to
the nerves which can be injured or damaged. Usually the numbness
or pain goes away, but in some cases, it may be permanent.
9.) Opening and/or infection of the sinus (a cavity in the upper jaw)
10.) Stiffness of the jaws or jaw joint
11.) Soreness and/or discoloration at the injection site if intravenous
medication is used
ANESTHETIC RISKS include: discomfort, swelling, bruising, infection, prolonged numbness and allergic reactions. There may be
inflammation at the site of an intravenous injection (phlebitis) that my cause prolonged discomfort and/or disability and may require
special care. Nausea and vomiting, although uncommon, may be unfortunate side effects of IV anesthesia. Intravenous anesthesia is
a serious medical procedure and although considered safe, does carry with it the rare risks of heart irregularities, heart attack, stroke,
brain damage or even death.
These possible complications occur very infrequently; however, any patient aware of the sequalae of non-treatment and unwilling to
accept the risk of these complications in order to obtain the benefits of treatment should not proceed with surgery at this time.
In the event that one of the health care “providers” sustains an exposure to my blood or body fluids during the procedure, I consent to
the drawing of my blood and performance of a rapid blood test for antibodies to the HIV 1 virus (known to cause AIDS), Hepatitis B, C
and Syphilis. This preliminary test will allow determination of whether urgent health care intervention for my health care provider is
needed. I will be informed about the results of any such testing.
I understand that my doctor can’t promise that everything will be perfect. I have read and understand the above and give my consent
to surgery. I have given a complete and truthful medical history, including all medicines, drug use, pregnancy, etc. I certify that I
speak, read and write English. All of my questions have been answered before signing this form.
_________________________________________
PATIENT (PARENT OR GUARDIAN IF MINOR)
_________________________________
WITNESS TO SIGNATURE- DATE