Patient Registration Form Patient Details

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Patient Registration Form Contact Information

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  •  Phone
  •  Email
  •  Text
  •  Mailing
  •  Website
  •  Social Media
  •  Google
  •  Radio
  •  Friend, Family or Coworker
  •  Other

Patient Registration Form Emergency Contact Information

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Patient Registration Form

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Patient Registration Form Patients Under 18

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Patient Registration Form Primary Insurance Details

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Please be advised that we file insurance as a courtesy. Expenses incurred in our office are the responsibility of the patient, not the insurance company. Should your claim be denied, payment in full is due immediately. Furthermore, if your insurance company has not responded to our claim within 45 days from the date of service, the entire balance will be transferred to you, the patient, for immediate payment.

  •  Full time
  •  Part-time

It may be necessary for you to provide, direct to your insurance company, proof of student status in order to process any claims.

Unfortunately, we are unable to accept assignment of benefits for a COBRA policy. We will give you a receipt showing procedure codes, but you must pay for your treatment as rendered.

Assignment of Benefits: I hereby authorize payment direct to Kellye N. Rice, DMD, PLLC for all dental services performed. I authorize the release of any dental information relating to my dental claim. I authorize the processing of my insurance claim via electronic transmission. I understand that my insurance coverage is based on a contract between the insurance carrier and my employer. Dr. Rice and her associates cannot be held responsible for changes in coverage, maximum limits and non-covered procedures.

Patient Registration Form

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ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES (HIPPA)

A copy of the Notice of Privacy Practices for Kellye N. Rice, D.M.D., P.L.L.C. has been made available to me. I am signing this form on behalf of myself and any of my dependents under the age of 18 who are, or will become, patients in this office.

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