Patient Registration Form - InStyle Dental

First Name*

Last Name*

Patient is:

Policy Holder

Responsible Party

Responsible Party (if someone other than the patient)

First Name

Last Name

Address

Address 2

City, State, Zip

Cell Phone

Home Phone

Work Phone

Ext

Date of Birth

Social Security

please choice atleast one from following

Responsible Party is also a Policy Holder for Patient

Primary Insurance Policy Holder

Secondary Insurance Policy Holder

Patient Information

Address

Marital Status

City

State, Zip

Home Phone

Cell Phone*

Work Phone

Ext

Referred By

Date of Birth

Age

Social Security

Email*

Section 2

Employment Status

Full Time

Part Time

Retired

Student Status

Full Time

Part Time

Medicaid ID

Employer ID

Pref. Dentist

Pref. Pharmacy

Carrier ID

Pref. Hyg

Section 3

Emergency Contact

Phone Number

Primary Insurance Information

Name of insured

Relationship to Patient

Self

Spouse

Child

Other

Employer

Employee Address

City, State, Zip

Occupation

Insurance Company

Insurance Address

City, State, Zip

Rem. Benefits

Rem. Deductible

DENTAL INSURANCE

BILL CLAIMS IN HOUSE or SELF BILL CLAIMS

If you have dental insurance, our office will assist you in obtaining the maximum benefits specified in your contract. However, your insurance contract is between you, your employer and the insurance company.

As a courtesy to you, we will file your insurance claim and accept assignment of benefits if you have signed the insurance payment authorization form. We ask that your estimated co-payment and deductible be paid at the time of service.

Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will cover, others they will cover partially, and some tat will not cover at all.

RELATED INFORMATION

Return checks are subject to a $25.00 Non-Sufficient Fund charge and balances older than 30 days will be subjected to an additional billing fee of 5% for every monthly statement sent. These additional fees will be applied to the unpaid balance at the end of the month.

In the event that the account is not paid and we refer the account to a collection agency, you will be responsible for all fees incurred for collection of your bill (i.e., attorney fees, court cost, and collection agency fees.) There is also a $50.00 fee to report your account to TRW.

Your appointment time has been reserved exclusively for you. Changes in your appointments affect your preventive care. We require 2 business days notice to avoid any charges. Failure to do so may result in a broken appointment fee. If your account becomes delinquent for more than 60 days and you are in need of additional treatment, fully payment must be made prior to the time of service.

I have read and understand that above information. I understand I am responsible (regardless of my insurance) for any charges incurred for services rendered.

NAME (Please Print)

Signature*

DATE

OFFICE USE ONLY

On this date, the Notice of Privacy Policy form was delivered. The form was not signed due to:

Untitled

COMMUNICATION BARRIER WHICH PREVENTED ACKNOWLEDGEMENT

AN EMERGENCY WHICH PREVENTED ACKNOWLEDGEMENT

A REFUSAL TO SIGN

OTHER

Monday	8:30am – 5:30pm
Tuesday	8:30am – 5:30pm
Wednesday	8:30am – 4:30pm
Thursday	8:30am – 5:30pm
Friday	8:30am – 5:30pm
Saturday	8:30am – 2pm (Pediatrics Only)