DeMercy Dental Crabapple Road, Ste. 140 Roswell, GA
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- Lawrence Blair
- 5 years ago
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1 PATIENT REGISTRATION (Please print) Patient s Legal Name: Last First Middle Preferred Name: Street Address: City St Zip Phone Numbers: Home Cell Work address: Which method is best to confirm appointments with you? Cell phone Home phone Work Phone Marital Status Single Married Widow Other Sex: Male Female Birthdate: / / Social Security #: / / Driver s License: State Issued: Exp. Date: Occupation: Employer: How did you hear about us? Family/Friend: Mailer: Website: Google: Dr. Other Whom may we contact in case of an emergency? Name: Phone Number: Relationship: ACCOUNT INFORMATION Person responsible for account: Name: Relationship: Phone: Address: Primary Insurance Company: Subscriber s Name: Subscriber s Birthdate: Social Security Number: Employer: Group Number: Member ID: Insurance Phone Number: Insurance Address: We invite you to discuss with us any questions regarding our services. The best dental health services are based on a friendly, mutual understanding between provider and patient. I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims on my behalf. I certify this information is true and correct to the best of my knowledge. I will notify of any changes. Date: Patient Signature
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4 FINANCIAL POLICIES Our office strives to offer the highest quality of care. Never will your care be contingent upon your insurance coverage. Your insurance coverage is considered a method of payment-never a method of treatment. We take considerable care in determining our fees We want to assure you that your charges accurately reflect the complexity of care rendered and the skill and expertise required for your care. Our fees are comparable to other general dentists in the area. Whether your insurance is self-purchased or provided through an employer, we will always go the extra mile to help you maximize your benefits. As a courtesy to you, we will file your primary insurance claims. Most dental insurance policies are not designed to pay for your entire treatment-it is only intended to cover a portion of the costs. We like to think of dental insurance as more of a "dental rebate". Please be aware that the financial obligation for services provided at are between the patient and the doctor, NOT the doctor and the insurance company. Payment to our office is not contingent nor dependent upon your insurance company. All account balances must be satisfied within 60 days of the date of service. After 60 days, a re-billing fee may be applied to your account. We accept cash, checks, VISA, MasterCard, American Express, and Discover. By signing below, you agree you are the responsible party for payment of all services regardless of dental insurance coverage or non-coverage. Additionally, you understand and agree to pay any and all collection costs and/or attorney's fees if any balance becomes delinquent and subsequently placed for collection with an outside agency. Date I hereby authorize assignment of my insurance benefits and rights directly to the provider for services rendered. I fully understand that I am solely responsible for any balance not paid by my insurance company. Date
5 INSURANCE INFORMATION Please indicate with your initials that you have read and understand each statement. *, as a courtesy, will file your insurance. * Our office staff will attempt to verify coverage, eligibility and an estimate of your benefits prior to your visit. * Estimates are not legally binding and often misunderstood or misinterpreted by the insured or insurer. * It is important for you to know what your insurance policy covers. We recommend that YOU check with your insurance company if you have any questions regarding your benefits. Most insurance companies only verify general benefit information to providers offices. * All phone verifications are a quote; this is NOT a guarantee of coverage or benefits. * ALL INSURANCE CLAIMS FILED CAN TAKE DAYS TO PROCESS. After 30 days, please contact your insurance company to check the status of your claim. Your insurance will send you an explanation of benefits approximately TWO weeks before they send payment to us. * All reimbursement decisions by your carrier are made strictly in accordance with plan provisions and patient eligibility at the time the services are actually performed. * IF you receive a statement from this office it is because there is an unresolved balance on your account. Please call immediately.
PATIENT REGISTRATION (Please Print) Social Security # Address City State Zip. Address
PATIENT REGISTRATION (Please Print) Date Name (Last) (First) (MI) Clinician Social Security # Address City State Zip Email Address Home Phone ( ) Mobile/Alt. Phone ( ) Work Phone ( ) PLEASE IDENTIFY WHICH
PATIENT REGISTRATION
TIME 10:15 AM PATIENT REGISTRATION DATE 6/15/2016 ID: Chart ID: First Name: Last Name: Middle Initial: Patient Is: Policy Holder Responsible Party Preferred Name: Responsible Party ( if someone other than
Today s date: PATIENT INFORMATION. Address:
Today s date: PATIENT INFORMATION Patient s last name: First: Middle: Please send appointment reminders to: Mobile phone #: Email Address: Mr. Mrs. Registration and Medical History Marital status Single
Secondary Insurance Information: Name of Insured: Relationship to Insured: Self Spouse Child Other
PATIENT REGISTRATION First Name: Last Name: Middle: Preferred Name: Patient is: Responsible Party Policy Holder Responsible Party: ( if someone other than the patient ) First Name: Last Name: Middle Initial:
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM Patient Last Name: First Name: MI: Address: State: Zip: Circle contact preference: Home Phone: ( ) Business: ( ) Cell: ( ) Email: Social Security #: Date of Birth: Age: Race:
Dental Insurance: Primary Carrier: Employee #: Insured s SSN #: Insured Birth date: Group #: Phone #: Insurance Company Address: City: State: Zip:
First Name: Middle: Last: Nickname: Date of Birth: Drivers License #: Male Female Single Married SSN #: Address: City: State: Zip: Home Phone: Work: Cell: Email address: Employer: Occupation: Spouse Name:
Keith Metzger, DDS, PC 1213 Hall Johnson Road, Suite 100 Colleyville, TX (817) ACKNOWLEDGEMENT OF RESPONSIBILITY
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Who may we thank for inviting you?
Please sign below after you read and understand our program and policies. Referral Program For every new patient you invite to Dr. Cariello, you will receive a $25 account credit to be used in our office.
Permission to Discuss Medical Information HIPPA PATIENT ACKNOWLEDMENT. Patient Name:
Patient Name: HIPPA PATIENT ACKNOWLEDMENT (Must be filled out by a parent/guardian if the patient is under the age of 18) We are required by law to maintain the privacy of protected health information
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New Patient Registration Form
New Patient Registration Form Patient Information Name: (First) (Middle) (Last) SSN: of Birth / / Sex: Male Female Street Address (or PO Box): City: State: Zip: Marital Status: Single Married Divorced
Has a family member been a patient in our office? Yes No
Patient Information *Please complete all pages First Name M.I. Last Address Sex M / F Age City State Zip Code Date of Birth Social Security Marital Status S M W D Primary Phone Alternate Phone E-mail Physician
INSURANCE INFORMATION
PATIENT INFORMATION Last Name First Name M.I. Marital Status: Married Single Divorced Widowed Social Security No.: - - Birth Date: / / Sex: M F Place of Birth: Driver s License Number: Preferred Language:
REASON FOR TODAYS VISIT Is this injury / condition related to your..
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Last Name: First Name: MI: Preferred Name: Name as on Insurance: SSN: - - (*Required for insurance claims) Address: City: State: Zip Code:
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Acknowledgement of Receipt of Notice of Privacy Practices By signing below I acknowledge that I have received the Notice of Privacy Practices of Cardiac Arrhythmia Institute, LLC, which explains its legal
Long Pond Pediatrics & Osteopathy Dr. Sabine M. Schmitt, DO, FAAP, C.S.P.O.M.M. Dr. Shoshana Katz, MD, FAAP Dr. Kimberly Ingalls, MD, FAAP, M.P.
Today s Date Long Pond Pediatrics & Osteopathy Dr. Sabine M. Schmitt, DO, FAAP, C.S.P.O.M.M. Dr. Shoshana Katz, MD, FAAP Dr. Kimberly Ingalls, MD, FAAP, M.P.H NAME OF PATIENT (CHILD) DOB SSN of child SEX
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