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PATIENT REGISTRATION

Name of Patient

Date

Gender

Female

Male

Date of Birth

Age

Social Security Number

Home Address

City

State

Zip

Home Phone

Business Phone

Mobile Phone

Dentist

Medical Doctor

Referred By

Drivers License Number

Nearest Relative

Phone

Have you ever been a patient of our practice?

Yes

Payment Method

Cash

Check

Credit Card

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Dental Insurance

Primary

Employer

Address

Phone

Plan

Insurance Company Name

Address

Phone

Group Name or Number

Insured Party

Relation

Date of Birth

Gender

Female

Male

Address

Phone

Social Security Number or ID

Medical Insurance

Primary

Employer

Address

Phone

Plan

Insurance Company Name

Address

Phone

Group Name or Number

Insured Party

Relation

Date of Birth

Gender

Female

Male

Address

Phone

Social Security Number or ID

Dental Insurance

Secondary

Employer

Address

Phone

Plan

Insurance Company Name

Address

Phone

Group Name or Number

Insured Party

Relation

Date of Birth

Gender

Female

Male

Address

Phone

Social Security Number or ID

Medical Insurance

Secondary

Employer

Address

Phone

Plan

Insurance Company Name

Address

Phone

Group Name or Number

Insured Party

Relation

Date of Birth

Gender

Female

Male

Address

Phone

Social Security Number or ID

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FEES AND PAYMENTS

We make every effort to keep down the cost of your oral surgical care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the fee for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorney’s fees, and court costs.

Patient Name

This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

AUTHORIZATION

I authorize my surgeon and his/her designated staff to perform an oral and maxillofacial examination for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all X-rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment.

Reviewed By

Signature of Doctor

Date

Signature of Witness

Date

ACKNOWLEDGMENT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I have received a copy of the Notice of Privacy Practices for the offices of Muir Oral, Facial, & Dental Implant Surgery. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Notice of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Notice of Privacy Practices is also posted in the facility. Muir Oral, Facial, & Dental Implant Surgery reserves the right to change the privacy practices currently described in the Notice of Privacy Practices. If Privacy Practices change, I will be offered a copy of the revised Notice of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a Notice of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.

ADDITIONAL DISCLOSURE AUTHORIZATION

In addition to the allowance disclosures described in the Notice of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare Information to the person(s) identified below. (I understand that the default answer is “NO.” Without indicating “YES” in answer to each individual question, personal protected health information (PHI) cannot be shared with anyone unless otherwise allowed by HIPAA rules.)

Spouse only

Yes

Any member of my immediate family (spouse, children, children's spouses)

Yes

Any member of my extended family (parents, grandchildren)

Yes

Other

Name of Patient

Patient's Personal Representative:

Personal Representative's Phone #:

Date

Signature of doctor

Signature of witness

witness signed date

doctor signed date

Mobile Users

Rotate your phone screen on the signature page to click the submit button.

Document Signers

- Signer 1

PATIENT REGISTRATION

Person Responsible

Spouse or other guarantor information (if different from above)

Patient Information

Dental Insurance

Medical Insurance

Dental Insurance

Medical Insurance

HEALTH HISTORY

Have you had, or do you currently have any, of the following?

MEDICATION

ALLERGIES

WOMEN ONLY

IN CASE OF EMERGENCY, CONTACT:

FEES AND PAYMENTS

ACKNOWLEDGMENT OF NOTICE OF PRIVACY PRACTICES