Who may we thank for inviting you?
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- Laureen Carr
- 5 years ago
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1 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. Simply make sure the people you invite mention you in their new patient paperwork. Who may we thank for inviting you? If you were not invited, how did you hear about us? Through my dental insurance On the Internet Google Yahoo Bing Yelp Facebook Healthprofs.com Healthgrades.com Other Please describe: Financial Policy Compensation for services is due when treatment is performed. Payment options include: cash, check, credit card, or financing through Chase Health Advance or Care Credit. We want to help you achieve your goals, so if you would like to discuss your payment options, please speak with Krystle, our Treatment Coordinator. Missed Opportunity Policy We are dedicated to give you the best care we can give. If you are unable to keep your appointment, please give us at least 24 to 48 hours notice so someone else may have the opportunity to take your place. If you cannot keep your appointment and cancel within 24 hours of your scheduled appointment, then we may charge you $50 for a missed opportunity with the Doctor and/or $30 for a missed opportunity with your Dental Hygienist. Thank you for your cooperation in this matter. Signature: Date:
2 Joseph Cariello D.D.S., P.C. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES * You May Refuse to Sign This Acknowledgement I, have received a copy of this office s Notice of Privacy Practices. Signature Date For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify)
3 282 Route Liberty Park Amherst, NH Phone: Fax: Date: Dear Dr. Please forward all records for to: Please forward all records for to: Dovetail Dental Associates Joseph Cariello, DDS 282 Route 101,5 Liberty Park Amherst, NH This request also applies to the following patient (s): D/O/B D/O/B D/O/B Please consider this signed form as an official release. Your prompt attention to this request is appreciated. Signature of patient or guardian: Printed name of patient or guardian:
4 TIME 12:36 PM DATE 1/20/2010 ID: Chart ID: First Name: Patient Is: Policy Holder Responsible Party Responsible Party (if someone other than the patient) First Name: PATIENT REGISTRATION Last Name: Preferred Name: Last Name: Middle Initial: Middle Initial: City, State, Zip: Home Phone: Pager: Work Phone: Ext: Cellular: Birth Date: Soc Sec: Drivers Lic: Responsible Party is also a Policy Holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder Patient Information City: State / Zip: Pager: Home Phone: Work Phone: Ext: Cellular: Sex: Male Female Marital Status: Married Single Divorced Separated Widowed Other Birth Date: Age: Soc. Sec: Drivers Lic: Section 2 Employment Status: Student Status: Medicaid ID: Employer ID: Carrier ID: Full Time Full Time Part Time Retired Part Time Pref. Dentist: Pref. Pharmacy: Pref. Hyg I would like to receive correspondences via . Section 3 Additional Who Comments: referred you?: Former Dental Office: Current PCP?: Primary Insurance Information Name of Insured: Relationship to Insured: Self Spouse Child Other Insured Soc. Sec: Insured Birth Date: Employer: Rem. Benefits:.00 Rem. Deduct:.00 Ins. Company: Secondary Insurance Information Name of Insured: Relationship to Insured: Self Spouse Child Other Insured Soc. Sec: Insured Birth Date: Employer: Ins. Company: Rem. Benefits:.00 Rem. Deduct:.00
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