Keith Metzger, DDS, PC 1213 Hall Johnson Road, Suite 100 Colleyville, TX (817) ACKNOWLEDGEMENT OF RESPONSIBILITY
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4 Keith Metzger, DDS, PC 1213 Hall Johnson Road, Suite 100 Colleyville, TX (817) ACKNOWLEDGEMENT OF RESPONSIBILITY I understand it is my responsibility to inform your office of any information changes, insurance changes, or phone/address changes at the time I sign in. Any information withheld could affect my insurance coverage and make me responsible for payment at the time of service. I have read, verified and complete all the information on the Patient Registration sheets, dated, and can attest to its accuracy to the best of my knowledge. I understand that I am legally responsible for all charges incurred for my care. Payment is expected when services are rendered, unless alternative arrangements have been made in advance. As a courtesy to me, the office of Keith Metzger, DDS, will attempt to gather as much information as possible regarding my insurance. It is my full responsibility to be aware of all coverage and benefits on my policy. I hereby authorize release of information necessary to file a claim with my insurance company and assign benefits otherwise payable to Keith Metzger, DDS. I understand that I am financially responsible for any balance not covered by my insurance company. I understand that any remaining balance which is over 30 days past due will be paid upon receipt of statement. I understand that any unpaid account is considered delinquent after 30 days and is subject to collection action, through a service reporting to credit bureaus. I understand that there will be a charge of $20.00 for any returned checks. I understand that If I am unable to keep my appointment, I must notify the office at least 24 hours before my scheduled appointment time. Signature Patient or legally responsible party Date
5 Keith Metzger, DDS, PC 1213 Hall Johnson Road, Suite 100 Colleyville, TX (817) INSURANCE INFORMATION AND AUTHORIZATION As a courtesy to you, our office is happy to help you process your insurance. We will do everything possible to help you understand and make the most of your dental insurance benefits. We realize that dental insurance is complex and that it is extremely difficult to understand how to work with certain dental insurance companies. As a result, we will provide full assistance to you. Insurance coverage is usually limited to a portion of the fee agreed to by you and our office. The benefits that you will receive are based on the terms of the contract that were negotiated between your employer and the dental insurance company. Unfortunately, some of the services that you may need will not be covered by your dental insurer. Our goal is to help you achieve and maintain optimal dental care, which is not necessarily the goal of the dental insurance companies. Our office will complete and submit dental insurance forms to the insurance company to achieve the maximum reimbursement to which you are entitled. We will work diligently to complete the process as quickly as possible. Please let us know if you have any questions about your dental insurance coverage. It will be our pleasure to help you. I authorize payment of benefits directly to the provider. I authorize the release of all necessary information to the insurance carrier and their representatives. I have read this form and agree to be financially responsible for items not covered by the insurance carrier. Date
6 Keith Metzger, DDS, PC 1213 Hall Johnson Road, Suite 100 Colleyville, TX (817) CREDIT CARD AUTHORIZATION So that we can keep our expenses and fees at the lowest level, we ask that you take care of the fees for your dental treatment at the time of service. If you wish to assign insurance benefits to us for services rendered, and acquire the privilege of our office extending the credit to you, we ask for your authorization to place any remaining balance which is over 30 days past due on your credit card. AUTHORIZATION: I authorize KEITH METZGER DDS, PC to keep my signature on file and to charge my credit card for any balance which is over 30 days past due. (This includes any bank charges incurred for insufficient funds). ( ) MasterCard ( ) VISA ( ) Discover ( ) American Express Patient Name Cardholder Name Cardholder Address City State Zip Code Credit Card Number Exp. Date Cardholder Signature
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ARTISTRY INTEGRITY PASSION 101 NORTH MARY STREET HEDGESVILLE, WV. 25427 NEW UPDATE Patient Information & Demographics Appointment : Appointment Time: am pm Name: Nickname: Address: of birth: SS# Marital