Alan D. Yount DMD-Patient Registration Form

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Patient Registration Form

Alan D. Yount DMD

333 North College Street,
Auburn, AL 36830
(334) 821-2404

Patient Details( * mandatory to fill )

First Name*

Last Name*

Preferred Name

Birth Date*

Address*

City*

State*

Zip*

Age

Sex*

Marital Status*

Soc. Sec*

Patient Is:

Policy Holder
Responsible Party

Drivers Lic

Contact Information( * mandatory to fill )

Home Phone

Pager

Cellular

Work Phone

Ext

Email*

I would like to receive correspondence via e-mail.

Responsible Party's Information( * mandatory to fill )

if someone other than the patient

First Name

Last Name

Middle Initial

Birth Date

Address*

City*

State*

Zip*

Home Phone

Work Phone

Ext

Cellular

Pager

Soc Sec

Drivers Lic

Responsible Party is also a Policy Holder for Patient
Primary Insurance Policy Holder
Secondary Insurance Policy Holder

( * mandatory to fill )

Employment Status

Full Time
Part Time
Retired

Student Status

Full Time
Part Time

Medicaid ID

Pref. Dentist

Employer ID

Pref. Pharmacy

Carrier ID

Pref. Hyg

Referred By

Previous Dentist

Emergency Contact

Emergency Contact #

Primary Insurance Information( * mandatory to fill )

Name Of Insured

Insured Soc. Sec

Insured Birth Date

Relation To Patient

Employer

Address

City

State

Zip

Insurance Company

Address

State

City

Zip

Rem. Benefits

Rem. Deduct

Secondary Insurance Information( * mandatory to fill )

Name of Insured

Insured Soc. Sec

Insured Birth Date

Relationship to Insured

Employer

Address

City

State

Zip

Ins. Company

Address

City

State

Zip

Rem. Benefits

Rem. Deduct

TCPA Prior Express Consent Notice( * mandatory to fill )

You agree, in order for us to service our account or to collect any amounts you may owe, we may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or emails, using any email address you provide to us. Methods of contact may include using prerecorded/ artificial voice messages and/or use of an automatic dialing device, as applicable. I have read this disclosure and agree that this office, or our assignee, may contact me/us as described above.

SIGNATURE (Patient/ Client Signature)*

(Please click below to draw/upload sign)

(Your IP Address : IP:34.204.173.45 )

HIPAA information and Consent( * mandatory to fill )

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy.

A Notice of Privacy Practices should be available to you in the office. The notice provides information about how we may use and disclose protected health information about you in order to carry out treatment, payment, and healthcare operations, and for other purposes permitted or required by law. The notice also contains information about your rights under the law.

Additional information is available from the U.S. Department of Health and Human Services.

By signing below you understand and agree to the terms of our notice of privacy practices which include:

• Protected health information may be disclosed or used for treatment, payment, or health care operations.
• Authorization is required for certain disclosures of your Protected Health Information.
• You have the right to opt out of fundraising communications.
• You have the right to restrict disclosures of your Protected Health Information under certain circumstances.
• You have the right to be notified of a breach of unsecured Protected Health Information.

By signing below you understand and agree that:

• The practice has a Notice of Privacy Practices that you have had the opportunity to review.
• The practice reserves the right to change the Notice of Privacy Practices and if we change our notice you may obtain a revised copy by contacting our office
• You may revoke this consent in writing at any time and all future disclosures will cease.
• The practice may condition treatment upon the execution of this consent.

Patient Details( * mandatory to fill )

Contact Information( * mandatory to fill )

Responsible Party's Information( * mandatory to fill )

( * mandatory to fill )

Primary Insurance Information( * mandatory to fill )

Secondary Insurance Information( * mandatory to fill )

Medical History( * mandatory to fill )

TCPA Prior Express Consent Notice( * mandatory to fill )

Patient Agreement( * mandatory to fill )

HIPAA information and Consent( * mandatory to fill )