Patient Registration
Personal Data
(Confidential)
Last Name_______________________________________
First Name_________________________MI___________
Date of Birth______________________Sex____________
Soc.Sec.#__________________Marital Status__________
(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_____________________________________
(Yellow Pages, Insurance Co., Location, etc.)
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.
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)________________________
Appointments: A fee will be charged for repeated
failed or canceled appointments without prior
notification of 24 hours. We realize that days old, I understand that Dr. Culberson will hire
emergencies do occur, so this charge is reserved for an attorney to obtain a judgement against me. In
repeated failure to keep appointments. Remember that event I will be responsible for paying the
that once your appointment has been arranged, this attorney's fee of 33-1/3% of the money that I owe
time has been reserved for you! Dr. Culberson or $150.00, whichever is greater.
I further understand that if I do not pay for Dr.
Insurance Claims: We are pleased that you have Culberson's services, my record of nonpayment may
chosen us to assess your periodontal status and we be reported to a credit reporting agency.
are here to help you in any way that we can. With
this policy in mind, as a service to our patients, we TO THE BEST OF MY KNOWLEDGE THE ABOVE
have been filing the claims to the carrier. We will CONFIDENTIAL INFORMATION IS TRUE. IF THE
ABOVE NAMED PATIENT IS A MINOR, I ALSO
promptly prepare necessary forms or reports to GIVE MY PERMISSION FOR TREATMENT. I
help you obtain your benefits, given the information AUTHORIZE DR. CULBERSON TO USE
you have provided to us. However, to avoid "SIGNATURE ON FILE" WHEN PROCESSING MY
misunderstanding regarding your treatment, please INSURANCE CLAIMS. FINALLY, I HAVE READ AND
UNDERSTAND THE ABOVE INFORMATION. I
remember that the financial obligations for AGREE TO ABIDE BY THE CONDITIONS
treatment rendered are your responsibility. Your DESCRIBED IN THIS DOCUMENT.
insurance coverage is a contract between you and
your insurance company and not between our office Signature________________________________________
and your insurance company. Receiving eligible ________________________
Date_____________________________________________
benefits for your insurance company certainly must _______________________
be a shared responsibility. If we must re-submit or Patient Information/Signature Witnessed and Reviewed
make telephone calls to your insurance carrier to by _____________________
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: There is a $25 fee for all
returned checks.
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