Patient Registration

Patient Registration Personal Data (Confidential) Last Name_______________________________________ First Name_________________________MI___________ Date of Birth______________________Sex____________ Soc.Sec.#__________________Marital Status__________

PLEASE ANSWER THE FOLLOWING QUESTIONS IF YOU HAVE AT LEAST ONE INSURANCE POLICY. WE ARE REQUIRED TO FURNISH THIS INFORMATION ON YOUR CLAIM FORM, EVEN IF YOU DO NOT HAVE ANY OTHER INSURANCE COVERAGE. THANK YOU.

(Minor, S M D W)

Address_________________________________________ _______________________________________________ City, State, Zip Code_____________________________ _______________________________________________ Phone: Home___________________________________ Patient or Parent Business________________Ext.________ Employer Name__________________________________ Employer Address________________________________ E-Mail Address __________________________________

Billing Information Person Responsible for your Account: Guarantor_______________________________________ Date of Birth _____________________________________ Soc. Sec. #_______________________________________ Address (if different)_______________________________ ________________________________________________

Referral Please Indicate How You Learned About Us: Referred by Another Dentist:________________________ Referred by Another Patient:________________________ Other Source_____________________________________

Are Other Family Members Employed? (Y/N)___________ Name:__________________________________________ Soc. Sec. #_______________________________________ Employer:_______________________________________ Employer Address_________________________________ _______________________________________________

Primary Insurance Person Insured____________________________________ DOB of Person Insured_____________________________ Relationship of Patient to Insured_____________________ Employer________________________________________ Employer Address_________________________________ Insurance Company_______________________________ Ins. Co. Address__________________________________ Ins. Co. Phone #__________________________________ Subscriber ID #______________Group #_______________ Insurance Type (Med/Dent)__________________________

Secondary Insurance Person Insured__________________________________ Relationship of Patient to Insured__________________ Employer_______________________________________ Employer Address________________________________ Insurance Commpany_____________________________ Ins. Co. Address_________________________________ Ins. Co. Phone #__________________________________ Group #________________________________________ Subscriber ID #__________________________________ Insurance Type (Med/Dent)________________________

(Yellow Pages, Insurance Co., Location, etc.)

Appointments: A fee will be charged for repeated failed or canceled appointments without prior

notification of 24 hours. We realize that emergencies do occur, so this charge is reserved for repeated failure to keep appointments. Remember that once your appointment has been arranged, this time has been reserved for you! Insurance Claims: We are pleased that you have chosen us to assess your periodontal status and we are here to help you in any way that we can. With this policy in mind, as a service to our patients, we have been filing the claims to the carrier. We will promptly prepare necessary forms or reports to help you obtain your benefits, given the information you have provided to us. However, to avoid misunderstanding regarding your treatment, please remember that the financial obligations for treatment rendered are your responsibility. Your insurance coverage is a contract between you and your insurance company and not between our office and your insurance company. Receiving eligible benefits for your insurance company certainly must be a shared responsibility. If we must re-submit or make telephone calls to your insurance carrier to check on claims, the additional staff time and expense is not covered in our fees for service. We ask that you be aware of correspondence from your insurance company, as you may receive correspondence before our office receives it. If your insurance company denies a claim or no correspondence has been received 30 days after your appointment, please help us by calling your insurance company to inquire about the status of your claim. Be aware that if we receive no correspondence from your insurance within 30 days of claim submission, you will be receiving a statement of your balance with our next billing cycle. Patient's understanding, patience and assistance in dealing with insurance claims make a big difference! Returned Checks: returned checks.

There is a $25 fee for all

Collections: All professional services rendered are charged directly to your account and you are personally responsible for payment of fees. I agree to pay a service fee of 1.5% per month on all money that I owe Dr. Culberson for more than 60 days. In the event that my account is more than 60

days old, I understand that Dr. Culberson will hire an attorney to obtain a judgement against me. In that event I will be responsible for paying the attorney's fee of 33-1/3% of the money that I owe Dr. Culberson or $150.00, whichever is greater. I further understand that if I do not pay for Dr. Culberson's services, my record of nonpayment may be reported to a credit reporting agency. TO THE BEST OF MY KNOWLEDGE THE ABOVE CONFIDENTIAL INFORMATION IS TRUE. IF THE ABOVE NAMED PATIENT IS A MINOR, I ALSO GIVE MY PERMISSION FOR TREATMENT. I AUTHORIZE DR. CULBERSON TO USE "SIGNATURE ON FILE" WHEN PROCESSING MY INSURANCE CLAIMS. FINALLY, I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION. I AGREE TO ABIDE BY THE CONDITIONS DESCRIBED IN THIS DOCUMENT. Signature________________________________________ ________________________ Date_____________________________________________ _______________________ Patient Information/Signature Witnessed and Reviewed by _____________________