Page 1 of 7

Patient Registration

General Patient Information

Patient Name

Date of Birth

Age

Sex

Address

Apt #

City

State

Zip

Primary Phone

Secondary Phone

Social Security Number

*Payment in full by cash, credit card, or money order will be accepted if you do not wish to provide your SS#

Drivers License: State and Number

Employer

Work Phone

Employer Address

Referring Doctor

Pharmacy You Use

Pharmacy Location or Cross Streets

IF PATIENT IS A MINOR: If the patient is under 18, the person accompanying him/her is responsible for the account. Please fill in the following information for the person who is in the office with the minor patient.

Parent or Guardian Name

Relationship to Patient if other than patient

Parent or Guardian Address

Parent or Guardian City

Parent or Guardian State

Parent or Guardian Zip

Parent or Guardian Phone

Parent or Guardian Alt Phone

Parent or Guardian Email

Parent or Guardian Social Security Number

*Payment in full by cash, credit card, or money order will be accepted if you do not wish to provide your SS#

Parent or Guardian Drivers License State and Number

Parent or Guardian Employer

Parent or Guardian Work Phone

Parent or Guardian Employer Address

Emergency Contact

Emergency Contact Name

Emergency Contact Primary Phone

Emergency Contact Relationship to Patient

Page 2 of 7

Insurance Information

Dental Insurance

Dental Insurance Company

Dental Insurance Company Phone

Dental Insurance Company Address

Dental Insurance Holder - Name

Dental Insurance Holder - SS or ID

Dental Insurance Holder - Date of Birth

Dental Insurance Holder - Employer

Dental Insurance Holder - Group ID

Medical Insurance

Medical Insurance Company

Medical Insurance Company Phone

Medical Insurance Company Address

Medical Insurance Holder - Name

Medical Insurance Holder - SS or ID

Medical Insurance Holder - Date of Birth

Medical Insurance Holder - Employer

Medical Insurance Holder - Group ID

Fees & Payments

Payment is expected at the time services are rendered. An estimate of your insurance benefits and coverage will be obtained by this office prior to any treatment; however, this is based upon information received from your insurance company and is not a guarantee of payment. It is your responsibility to pay any deductible amount, co-insurance, or any other balance denied by or not paid by your insurance company.

I hereby authorize the release of information necessary to process the claim(s). I authorize the use of this signature on all of my insurance claims, manual or electronic. I further authorize payment to Dr. Kunkel, including benefits otherwise payable to me. I understand that I am responsible for the payment of services rendered in full, regardless of payments expected by an insurance company. My signature below states that I have answered all the above questions to the best of my knowledge.

Consent for Diagnostic Aids

I hereby give my consent to Dr. Kunkel for any diagnostic aids necessary to evaluate, document, and/or diagnose my condition. These shall include, but are not limited to, radiographs, models, and photographs. I also release to Dr. Kunkel any medical or dental information to evaluate and/or treat my condition.

NOTE: You will be asked for an electronic signature after you complete all 7 pages.

Page 4 of 7

Patient HIPAA Consent Form

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.

As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we use and disclose your health information.

We may use and disclose your medical record only for each of the following purposes: treatment, payment, and healthcare operations.

• Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would be your office visit,
hospital visit, or test.
• Payment means such activities as obtaining reimbursement for
services, confirming coverage, billing or collection activities, and utilization reviews. An example of this would be sending a bill for your visit to your insurance company for payment.
• Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost management analysis, and customer service. An example of this would be an internal quality assessment review.

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Any
other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing, and we are required to honor and abide by that written request,
except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Office:

• The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to your request for restriction. If we do agree to the restriction, we must abide by it unless you agree in writing to remove it.
• The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
• The right to inspect and copy your protected health information.
• The right to receive an account of disclosures of protected health information.
• The right to obtain a paper copy of this notice from us upon request.

This consent was signed by

Relationship to Patient

Page 5 of 7

Authorization to Release Health Care Information

The top part of this page is optional for patients over the age of 18. Due to the federal privacy laws, our office is not allowed to discuss any information regarding your medical records, account, etc., with anyone other than you directly. You will want to complete this form if you anticipate anyone calling on your behalf. This form does not apply to any physicians discussing treatment with each other.

I request and authorize Dr. Kunkel to release health care information of the patient named above to the following individual(s):

HIPAA Authorized Person 1

HIPAA Authorized Person 1 Relationship

HIPAA Authorized Person 2

HIPAA Authorized Person 2 Relationship

I may cancel this authorization to the extent allowed by law. If I do, I understand that the doctor or practice may have already released information about me after I gave permission. I know that canceling this authorization would not prohibit any release of information by the doctor or practice in reliance on my original authorization.

Once my doctor gives out the information that I want released, I know that my doctor has no control over the information. The individual or organization that I authorized to receive the information might re-dislose it. Federal or state privacy laws may no longer protect the information.

The office of Dr. Kunkel may be leaving messages at the home number or the contact number provided* *If you do not wish to have a message left for you, please let us know.

The office of Dr. Kunkel reserves the right to modify the privacy practice outlined in the notice located in the reception area.

A copy of the Notice of Privacy Practices for Dr. Kunkel has been made available to me, and I have had the opportunity to read the information.

*By state law, if you are prescribed a controlled substance, your identifying information will be entered into a statewide database of controlled substance prescriptions.

Page 6 of 7

Financial Policy

Dr. Kunkel and his staff welcome you to our office, and we thank you for choosing us as your health care provider. We are committed to delivering your care in the most considerate and professional manner. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our financial policy, which we require you to read and sign prior to any evaluation or treatment.

Our Financial Policy:

Our office has established procedures that maintain quality care and reasonable cost for our patients. Charges for your exam, x-rays and any other diagnostic aids obtained during your first appointment are due at that time. These fees will be filed to your insurance. Any payments received by your insurance for these charges will be applied to your account if there is a current balance, or a refund will be issued to you. If your surgery is not covered by insurance, or if you desire to have your exam and treatment performed on the same day (i.e., emergency patients), we will require payment in full by cash, credit card, personal check, or cashier’s check prior to any treatment. The fees quoted are an estimate only. If the procedure proves to be more complex than anticipated, the fees will be adjusted accordingly. The stated fees will be honored for a period of 6 months. After that period, you may be required to be seen for an updated exam prior to surgery, which may be an additional cost.

Your Insurance Coverage:

As a courtesy to you, we will file your insurance claim, and we will accept payment of insurance benefits after your first visit. However, based on what your insurance company reports to us, we do require that your estimated portion, including any deductible of treatment, be paid at the time of surgery. If your insurance company has not paid your account in full within 60 days, the account will be due, and you will be sent a statement requiring payment of the balance within the next 10 business days. Once all insurance benefits are received, we will gladly reimburse you any overpayment. We must remind our patients that insurance is a contract between you and your insurance company to pay certain amounts for medical care. Your bill is a contract between you and your doctor and does not involve the insurance company, even when we file the insurance claim for you. In short, you are responsible for any and all charges not paid by your insurance carrier, and your financial obligation for payment is not dependent on insurance coverage.

Regarding Managed Care Plans for which we are a participating provider, all co-pays and deductibles are due prior to treatment. In the event that your insurance coverage changes to a plan for which we are not participating providers, refer to the above paragraph. If you have Medicare, you must sign a “private contract” showing you will be responsible for all charges. As a service to our patients, we are pleased to participate in the following credit plans: Care Credit and Lending Club.

Usual & Customary Rates:

Our practice is committed to providing the best treatment for our patients, and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary “schedule” of fees, which

often bears no relationship to the current standard and cost of care in this area.

Delinquent Accounts:

All accounts which remain unpaid after the aforementioned period of time will be sent to our collection services. We realize that temporary financial problems may affect timely payment of your account. If such problems arise, we encourage you to contact us promptly for assistance in the management of your account.

We do ask you to be on time to your appointment. If you are late, your appointment may be rescheduled at the office’s discretion. This is for us to give you the best care possible.

A service charge of $75.00 will be added if a surgery appointment is cancelled less than 24 hours from the appointment. A service charge of $25.00 will be assed on all returned checks.

Should it become necessary for this office to employ an attorney to enforce payment for treatment rendered, the patient agrees to pay reasonable attorney’s fees, court costs, and interest incurred for such enforcement.

Thank you for taking your time to review our financial policy. Should you have any questions or concerns, we would welcome the opportunity to discuss them with you. Your signature below indicates that you have read, understood and agreed to this financial policy and that you will be responsible for payment in full of this account.

Page 7 of 7

Michael Kunkel,DDS

Are you enrolled in Medicaid or Medicare?

Currently enrolled with Medicare.

Currently enrolled with Medicaid.

For MEDICAID patients only: Dr. Kunkel is not currently accepting Medicaid patients at this time. You may be required to find a participating Medicaid provider.

Dr. Kunkel does not participate in the Medicare program because:

Most dental services, including oral surgery, are not a covered benefit;
Medicare provides very low payments for the few oral surgery services covered;
Medicare delays the processing of claims submitted.

Dr. Kunkel does provide his services to Medicare-eligible patients.

However, Medicare requires that its insured person enter into a “private contract” with providers who are not contracted with Medicare. If you choose to have Dr. Michael Kunkel provide

services, you must enter into the “private contract” below.

Private Contract

This contract is between Dr. Kunkel and the above-named patient. Oral surgery services will be provided according to the treatment plan agreed upon between Dr. Kunkel and the patient (or his/her legal representative). Dr. Kunkel will charge the established fees for these services. Payment by the patient will be in accordance with Dr. Kunkel’s financial policy. To signify agreement with these terms, the patient, or his/her legal representative, has signed below.

Document Signers

- Patient