We would like the option of creating a shorter/customized Patient Registration Form. The existing form is too long, per patient feedback. See example below. Case # 05287893
Patient Name: _________________________________________________________ ______________________
Preferred Name
Title: ☐Mr.☐Mrs.☐Ms. ☐Dr.☐Other _______ Gender: ☐ Male ☐ Female ☐Other
Birth Date: ________________ Family Status: ☐Married ☐Single ☐Child ☐ Other
MailingAddress:_____________________________________________________________________________________
City: ___________________________________________ State:______________ Zip Code:_____________________
Email Address: __________________________________________________________________________
Phone: Mobile_________________________ Work:_____________________________________
Home:__________________________ Other:_____________________________________
Please check all that apply:
☐You may contact me at my Mobile number ☐You may contact me at my Work number
☐You may contact me at my Home number ☐You may send me emails
Whom may we thank for referring you to our practice?
Referral Name:______________________________________________________________________________________
In an emergency, who should be notified? Please enter the Name and Phone Number below:
Emergency Contact:__________________________________________________________________________
Name Phone Number
RESPONSIBLE PARTY INFORMATION
☐I am financially responsible for my account. (Skip this section and continue to Dental Insurance section)
Responsible Party Name:____________________________________________________________________________
Mailing Address: ____________________________________________________________________________________
City:______________________________________________________ State:_________ Zip Code:___________
Relationship to Patient: ☐Spouse ☐Parent ☐Other
Responsible Party Email Address: ___________________________________________________________________
Responsible Party Mobile Number:___________________________________________________________________
Responsible Party consents to receive billing and payment text messages. ☐YES ☐NO
PRIMARY DENTAL INSURANCE INFORMATION
Name of Insured: _________________________________________________________________________________
Insured’s Address: _________________________________________________________________________________
City:_____________________________________________________ State:_______________ ZipCode:______
Insured’s Relationship to Patient: ☐Self ☐Spouse ☐Parent ☐Other
Insured’s Date of Birth:_______________________ Name of Employer:___________________________________
Insurance Company Name___________________________________________________________________________
Insurance Address________________________________________________________________________________
City: _______________________________________________ State:_____________ Zip __________________
Insured’s ID Number:_______________________________ Group Number:______________________________
Please provide our office with a copy of your dental insurance card if available.
Do you have Secondary Dental Insurance? ☐YES ☐NO
If YES, complete the following section. If NO, skip to Insurance Authorizations.
SECONDARY DENTAL INSURANCE INFORMATION
Name of Insured: ___________________________________________________________________________________
Insured’s Mailing Address:___________________________________________________________________________
City:____________________________________________________ State:_____________ Zip____________
Insured’s Relationship to Patient: ☐Self ☐Spouse ☐Parent ☐Other
Insured’s Date of Birth:_______________________ Name of Employer:___________________________________
Insurance Company Name___________________________________________________________________________
Insurance Address___________________________________________________________________________________
City: _______________________________________________ State:_____________ ZipCode:______________
Insured’s ID Number:_______________________________ Group Number:______________________________
Please provide our office with a copy of your dental insurance card if available.
INSURANCE AUTHORIZATIONS
I authorize my insurance company to pay the dentist all insurance benefits rendered.
I authorize the use of electronic signatures on all insurance submissions.
I authorize the dentist to release all information necessary to secure the payment of benefits.
I understand that I am financially responsible for all charges whether or not paid by insurance.
☐By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the Administration Form.
FINANCIAL POLICY STATEMENT
Payment for services, including deductibles and copayments, are due at the time of the service unless other arrangements have been made prior to treatment. Payments may be made using cash, check, or credit cards. Any arrangements for financing must be made before starting treatment.
Restorative treatment requiring laboratory processing will require 50% of treatment costs as down payment to begin treatment and the balance at the delivery of prosthesis (unless other payment arrangements have been made). Please speak with a business administrator if you have any financial questions.
Our office is out-of-network with most dental insurance plans. We recommend you verify your plan has out-of-network benefits prior to scheduling with our office. If you are covered by a Delta Dental Premier plan and would like to stay in-network, please schedule your appointments with one of our in-network providers.
We are happy to submit dental claims on your behalf; however, the insurance contract is an agreement between you and the insurance company. You are ultimately responsible for all charges. We cannot guarantee that any coverage estimated by your plan will be paid once a claim is filed. Please note that dental insurance is intended to cover some but not all dental care costs, and not all services are covered by your plan. You are responsible for payment of all services regardless of the payable benefit.
* By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the AdministrationForm.
APPOINTMENTS
While our office attempts to confirm all appointments in advance, it is your responsibility to remember your scheduled appointment. We value your time and ours; if you are unable to keep an appointment, be courteous and kindly notify our office at least 24 hours prior to the appointment. Failure to arrive for an appointment without 24-hours' notice will incur a Broken Appointment fee of $100 per hygienist appointment and $150/hour per doctor appointment, payable prior to rescheduling another appointment and not billable to insurance.
* By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the AdministrationForm.
LATE ARRIVAL POLICY
If a patient is more than 10 minutes late or an appointment, the appointment may need to be rescheduled. This is to ensure that the patients who arrive on time do not wait longer than necessary to see the provider. We will make every effort to honor your appointment as a "work-in" as the schedule allows upon arrival, but there may be times when this will not be possible, and you will have to be rescheduled.
* By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the AdministrationForm.
RETURNED CHECK POLICY
Checks that are returned to our office from your financial institution are subject to a $50.00 returned fee.
* By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the AdministrationForm.
HIPAA ACKNOWLEDGEMENT
I understand that I may inspect or copy the protected health information described by this authorization.
I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form.
I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality,
Please list authorized persons with whom we may discuss your Protected Health Information (PHI) in addition to custodial parents and legal guardians: (example: John Doe (212-555-1212)
CONSENT FOR INTERNET COMMUNICATIONS
I grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured web site for the dental practice. I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload and use my information in connection with the operation of such services and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the web site on my behalf. I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES.
* I have read the information above regarding the secured uploading of patient information to the web site for the dental practice and grant the dental practice permission to securely upload my patient information to the web site.
Name of the person completing this form___________________________________________________________
Relationship to Patient: ______________________________________________________________________
Date:______________________________
Guest
