Patient Registration Form

Financial Agreement

PLEASE READ CAREFULLY BEFORE FILLING OUT THE FORMS

We kindly ask our patients to fill out all forms thoroughly and properly. Each form is very important to our doctors and staff. Any forms that are not fully filled out will be considered incomplete and unacceptable. All forms must be completed including your name and date of birth at the top of each page. Forms are not valid when there is only a signature and no printed name for the patient. It is very essential that each form has all of your information filled out entirely. Thank you in advance for your cooperation.

Initials:

Use your mouse or finger to sign in the box below.

First Name: *

Last Name: *

Email: *

Phone: *

D.O.B:

Home Phone:

Emergency Contact:

Telephone:

Primary Dental Insurance

Insurance Company:

Group:

Subscriber ID#:

S.S. #:

Subscriber’s Name:

D.O.B:

Employer:

Employer’s #:

Secondary Dental Insurance

Insurance Company:

Group:

Subscriber ID#:

S.S. #:

Subscriber’s Name:

D.O.B:

Employer:

Employer’s #:

Please Let Us Know How You Heard About Our Office:

Date:

Patient/Guardian Signature:

Use your mouse or finger to sign in the box below.

Financial Agreement

We are committed to providing you with the best possible dental care. Our fees reflect our professional commitment to excellence. In order to achieve these goals, we need your assistance and understanding of our payment and financial policy. We offer the following methods of payment:

For patients with insurance, we will accept payment directly from the insurance company, but require that any co-payments, deductibles and non-covered fees are paid on the date of service.
Payment in full is due at the time of service, unless other arrangements have been made with a detailed and signed financial agreement. Cash, Check, Debit Card, MasterCard, Visa, Discover and American Express are accepted.
For patients without insurance, we collaborate with Care Credit as a financing option. Care Credit can help patients finance larger dental cases with no required down payment and payments can be made up to 12-18 months with no interest rates. Applications can be completed online at www.carecredit.com or in office with the assistance of our receptionists.
Patients are also able to sign up for Careington1 discount plan in order to receive discounted fees.

Important Information Regarding Your Dental Benefits

Your dental benefit program is a contract between you, your employer, and the insurance company. We are not a party to that contract. This office files your insurance as a courtesy to you.
Not all dental services are a covered benefit in all contracts. It is your responsibility to know your benefits. You (not the insurance company) are responsible to us for all our fees for services rendered to you.
An ESTIMATE will be given of the benefits that the insurance company is expected to pay. Remember that this is only an ESTIMATE and that the actual cost may vary.
Any parent/guardian bringing a child to our office is legally responsible for payment of all services rendered. We do not bill individual parents for child's co-payment.

BROKEN/MISSED APPOINTMENT: Appointments reserve a specific time with the dentist or hygienist to perform and provide the care you need. These scheduled times are planned for your convenience and hold great value. We require a 24-hour notice of canceling or rescheduling your appointment; if a 24 hours' notice is not given, a $45.00 fee will be charged.

I acknowledge I have received and agreed to MidJersey Dental's Payment & Financial Policies. Patient or Responsible Party:

Patient Name

Signature:

Use your mouse or finger to sign in the box below.

Notice of Privacy Practices

I understand that under the Health Insurance Portability and Accountability Act of l 996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly
Obtain payment from third-party payers.
Conduct normal healthcare operations, such as quality assessments and physician certifications.

I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions.

Patient Name:

Relationship to patient:

Date:

Patient Signature:

Use your mouse or finger to sign in the box below.

(CID : 22857)

Patient Intake Form

Patient Intake Form

Financial Agreement

PLEASE READ CAREFULLY BEFORE FILLING OUT THE FORMS

Primary Dental Insurance