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Patient Registration Form

Rene Horvilleur DDS

The Graybar Building 420 Lexington Ave Suite 228,
New York, NY 10170
(212) 867-6768

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
PRIMARY DENTAL INSURANCE( * mandatory to fill )

Name of Insured

SECONDARY DENTAL INSURANCE( * mandatory to fill )

Name of Insured

ASSIGNMENT AND RELEASE OF INSURANCE

  •  By checking this box

I certify that I (or my dependent) have insurance as provided above and assigned directly to Dr. Rene Horvilleur all insurance benefits, if any, otherwise payable to me for services rendered.

I understand that i am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits.

I authorize the use of my signature (signed at the end of the registration) on all insurance submission.

Medical history( * mandatory to fill )

Indicate which of the following you have had or have at present. By checking the box it will indicate a "Yes" response, leaving blank will indicate a "No" response.

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  •  By checking this box, I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly. I am aware that I must notify the practice of any future changes.
Financial Policy( * mandatory to fill )

Thank you for choosing us for your dental needs. We are committed to providing you with excellent care. Our convenient financial arragnements are based on an open and honest discussion of recommended treatment options, respective fees and patient's financial capabilities.

PAYMENT

Non- covered payments are due in full at the time of service, unless prior financial arrangements are made. We do offer several payment methods including:

* Cash

* Check

* Visa, Master Card, Discover,American express

* Care credit

* Apple pay, Android pay

COPAYMENT

Copayments are based on your insruance provider. Our staff will be glad to assist you in letting you know what your copayment amount is for each of your visits

INSURANCE

Our office is committed to helping patients maximize their benefits. Some insurance companies require the patients to pay upfron and then reimburse them for the services rendered. For these scenarios, we will estiamte your coverage in good faith, but cannot guarantee there are the amounts. As a service to our patient, we ware happy to manage the claim submission and following up on your behalf. After your treatment services have been submitted, please allow up to 30 days to receive your direct reimbursement from your insurance company. If you have any questions, our staff is always available to answer your questions. For hose aptients that are covered by insurance(s), which pay out the practice directly, this will be considered your method of payment.

MINORS

Payment for servces for the treatment of minor can be made by any payment method stated above and is the responsibility of the adult accompanying that minor.

SERVICE CHARGE

This office policy is to charge 1.5% monthly interest (18% annually) to all accounts that are 90 days overdue. There will also be a fee of $50 for any returned checks.

BROKEN APPOINTMENT

We understand that there may be circumstances where you may need to reschedule or cancel an appointment. In the events that this occurs, we do ask for a 2-DAY NOTICE IN ADVANCE. If your records indicate that you have 2 or more missed appointments. There will be a $50 NON- REFUNDABLE charge for canceling the day before or $100 NON- REFUNDABLE charge for same day cancellation added to your account.

  •  By checking this box, I have read and fully understand the financial policy for the office.

By signing below, I acknowledge that I have read and fully understand all terms and contents in completion of this registration.

(Please click below to draw/upload sign)
(Your IP Address : IP:3.236.15.142 )
Disclosure form( * mandatory to fill )

I, or my authorized representative, request that health information regarding my care and treatment as set forth on this form:

In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that:

1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV RELATED INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8.

2. If I am authorizing the release of HIV-related, alcohol, or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights.

3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.

4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.

5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law.

6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).

7. Name and address of health provider or entity to release this information:

8. Name and address of person(s) or category of person to whom this information will be sent:

 

  •  Medical Record form (insert date)to (insert date)
  •  Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers.
  •  Other
  •  Alcohol/Drug Treatment
  •  Mental Health Information
  •  HIV-Related Information
  •  Genetic Testing
  •  By initialing here i authorize

to discuss my health information with my attorney, or a governmental agency, listed here:

  •  At request of individual
  •  Other

All Items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form.

 

(Please click below to draw/upload sign)
(Your IP Address : IP:3.236.15.142 )

* Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify someone as having HIV symptoms or infection and information regarding a person’s contacts.

Xray release( * mandatory to fill )

I, the patient, hereby am requesting and allowing the release of my xrays taken at Dr. Rene Horvilleur's office to be release to (Please include the name and email address of the receipent of xrays):

 

By signing below, I certify that I have authorize the request and release of xrays.

(Please click below to draw/upload sign)
(Your IP Address : IP:3.236.15.142 )

If patient is a minor (under the age of 18), please state your relationship to the patient.

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