Patient Registration Form Patient Details

Patient Registration Form Contact Information

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Patient Registration Form Emergency Contact Information

Patient Registration Form BILLING INFORMATION

Patient Registration Form MEDICAL INFORMATION


By filling out this paper I authorize my insurance benefits to be paid directly to Dr. Michael Merkley. I am responsible for services not covered. I authorize the release of any dental information or radiographs to process my claim including electronic claims submission

I have read and agree to the terms of the listed documents:


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Patient Registration Form Medical History

  •  AIDS/HIV positive
  •  Blood Thinners
  •  Hepatitis
  •  Premed Necessary
  •  Excessive Bleeding
  •  Cancer
  •  High Blood Pressure
  •  Pacemaker/Defibrillator
  •  Stroke
  •  Heart Surgery
  •  Asthma
  •  HPV
  •  Heart Murmur
  •  Nervous Disorder
  •  Sinus Problems
  •  Thyroid Disease
  •  Respiratory Problems
  •  Dizziness
  •  Liver Disease
  •  Rheumatic Fever
  •  Anemia
  •  Epilepsy
  •  Kidney Disease
  •  Radiation Treatment
  •  Ulcers
  •  Sleep Apnea
  •  Diabetes/Hypoglycemia
  •  Eating Disorder
  •  Intestinal Problems
  •  Acid Reflux/Heart Burn
  •  Tuberculosis
  •  Drug or Alcohol Addiction
  •  Arthritis
  •  Fainting
  •  Osteoporosis
  •  Stomach Problems
  •  Artificial Joints
  •  Heart Disease
  •  Mental Illness
  •  Rheumatism
  •  Auto Immune Disease
  •  Latex Allergy
  •  Allergies- Anesthetic
  •  Allergies - Hay fever
  •  Allergies- Metal
  •  Allergies- Medication
  •  Allergies - Other
  •  Are you taking any medications for osteoporosis/osteopenia
  •  Ever been hospitalized (illness or injury)
  •  Presently being treated for any other illness
  •  A smoker or smoked previously/chewing tobacco
  •  Female: Taking birth control pills
  •  Currently Pregnant/nursing
  •  Excellent
  •  Good
  •  Fair
  •  Poor

Patient Registration Form Dental History

Please answer the following dental questions:

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

By signing this form, You acknowledge that you have reviewed ALL questions/alerts on this questionnaire and responded accordingly. There are not other medical conditions or medications/allergies that have been not listed. I am aware that I must notify the practice of any further changes.

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Patient Registration Form Financial Agreement

This statement was prepared in an effort to avoid any misunderstanding which may arise regarding your account with this office and/or your insurance company. We will try in every way we can to make the processing of your insurance as simple as possible. Please remember, it is your insurance so it is your responsibility to know your insurance benefits and limitations. We do not accept responsibility for collecting your unpaid insurance claim. It is your responsibility to see that your insurance company pays that part of your bill which is covered by your policy, within a reasonable length of time (30 days). You are responsible for the payment of your account.

Payment Agreement;

* Payment is due in full at the time of treatment unless prior arrangements have been made.
* We accept all major credit cards
* If you have the type of insurance where reimbursement checks are sent directly to you, the full cost of treatment is due the day of your appointment.
* Payments on your account are due on the 10th of each month. Late payments will incur a $5 late payment fee.
* Balances over 60 days incur a 1.75% finance charge per month.
* There is a fee of $20.00 for all returned checks
* Appointments missed without 48-hour cancellation notice will incur a charge of $50 for each 1⁄2 hour reserved for your appointment.
* In the unfortunate event that your unpaid account is placed with a collections agency or lawyer, you agree to pay the remaining balance plus all collection/court costs and fees (a minimum of 40% of the balance).

Insurance: Where insurance benefits apply an estimated portion is expected in advance or on the day of service. Because we cannot guarantee the amount of coverage the insurance provides, any difference from our estimate should be paid immediately following the insurance payment. You the patient, accept responsibility to pay the balance in full immediately if the insurance has not paid within 60 days. If the insurance company pays more than estimated we will be happy to credit your account for future services or write you a reimbursement

Grounds for dismissal: Most of our patients stay with our practice for many years. There are rare occasions when we find it necessary to dismiss a patient from our practice with or without cause. These reasons include but are not limited to the following: repeated missed appointments without good cause, failure to abide by the financial policy, noncompliant or abusive behavior or dishonesty in the information you provide.

We are here to help you. If you have questions or concerns regarding your account, please do not hesitate to ask. Good communication can help us to help you. Please visit our financial secretary; she is here to help you.

 By my initial on the patient information sheet, I certify that I have read and understood the office financial agreement. I am aware of my insurance benefits and limitations. I agree to abide by the terms explained in this agreement.

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Patient Registration Form HIPAA

You acknowledge and give consent to Dr. Michael Merkley to use and disclose your protected health information and that of your immediate family members for the purposes of treatment, payment and health care operations. Our Notice of Privacy Practices provides more detailed information about how we may use and disclose this protected health information. You have a legal right to review our Notice of Privacy Practices before you sign this consent, and we encourage you to read it in full.

Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by contacting our office and requesting a copy of our then-current Privacy Practices.

You have a right to request us to restrict how we use and disclose your protected health information for the purposes of treatment, payment or health care operations. We are not required by law to grant your request. However, if we do decide to grant your request, we are bound by our agreement.

You have the right to revoke this consent in writing, except to the extent we already have used or disclosed your protected health information in reliance on your consent.

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