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Patient Registration Form

Sarah J Morris & Associates

2551 River Park Plaza,
Fort Worth, TX 76116
(817) 732-4419

PATIENT DETAILS( * mandatory to fill )
FINANCIAL INFORMATION( * mandatory to fill )
  •  Yes
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DENTAL INSURANCE INFORMATION( * mandatory to fill )
HEALTH QUESTIONAIRE( * mandatory to fill )

Are you allergic to

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FEMALE

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I hereby acknowledge that I have provided the above health information to Dr. Sarah Morris and that it is true and accurate.

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DENTAL QUESTIONAIRE( * mandatory to fill )
  •  Hot
  •  Cold
  •  Sweets
  •  Chewing/Pressure
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I hereby acknowledge that I have provided the above dental information to Dr. Sarah Morris and that it is true and accurate.

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Consent for Services

I hereby authorize the doctor to perform any and all forms of treatment, medication, and therapy, that may be indicated in connection with the dental care of the patient named above and further authorize and consent that the doctor chooses and employs such assistance as he deems fit. I also understand that previous to treatment, full explanation of the procedures involved will be given by the doctor and/or his staff. I agree to pay for all services rendered by this office. I also understand and agree that any all past due balances over thirty days will be subject to a 1.5% finance charge per month as allowed by Texas state law.

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SERVICE ACKNOWLEDGMENT( * mandatory to fill )

Assignment of Insurance Benefits

In consideration of services rendered, I hereby transfer and assign to Sarah J. Morris, DDS PLLC, 2551 River Park Plaza Suite 210, Fort Worth, Texas, 76116, all right, title and interest in any payment due for services as provided in the policy or policies of dental insurance held by me.

I agree to pay, at Fort Worth, Tarrant County, Texas the charges of Sarah J. Morris, DDS PLLC, which exceed the amount paid by the insurance policies held by me. I further agree and authorize Sarah J. Morris DDS PLLC, to release any information requested by the insurance company(s) or its representatives. I understand that filing of my dental insurance is done as a courtesy to me.

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Agreement to Pay for Services Rendered

I agree to pay for all services rendered by Sarah J. Morris DDS PLLC. I further understand that I am legally responsible for all cost of treatment, regardless of any estimated insurance balance. I also understand and agree that any and all past due balances over thirty (30) days will be subject to a finance charge as allowed by the laws of the State of Texas.

I acknowledge that I have received a copy of the Notice of Privacy Practices (HIPAA).

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I agree to allow Sarah J. Morris, DDS PLLC and her employees to use any photographs of any portion of my dental treatment for the purpose of teaching, in dental publications and in any medium including but not limited to the internet. I have been advised that no identifying information is ever attached to any photograph.

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Preferred method of contact for dental information and/or appointment details

  •  Yes
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I hereby authorize Sarah J. Morris DDS PLLC, to release dental information regarding myself by the preferred method of contact selected above.

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I have read the above conditions of treatment and payment and agree to their content.

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FINANCIAL POLICY FOR OUR PATIENTS( * mandatory to fill )

 

We do not participate in any DMO/HMO dental plans or reduced fee schedule plans.

 

Our office understands the value of dental insurance and will file dental claims on your behalf. We will accept the assignment of your benefits this means that you must agree to assign your benefits to us so that we may receive payment from your dental insurance carrier. We will complete and process all insurance claims forms for you.

 

Most dental insurance plans do not cover 100% of the cost of your treatment. Because of this, and a delay in receiving payment from the insurance company, you will be asked to pay your deductible as well as your estimated portion of your charges the day services are rendered.

 

We will estimate as closely as possible your coverage, but until we actually receive payment from your insurance carrier, it is just that- an estimate. If we do not receive payment from your carrier with 30 days, the entire balance is due from you. 

 

Please understand that we file and accept assignment of your insurance benefits as a courtesy to you. If your insurance denies coverage or does not pay for any reason, you are ultimately responsible for any and all charges incurred in our office. 

 

Payment Options

 

Our office accepts cash, personal checks and all most credit cards for services. We do not finance any dental work ourselves. For those patients who require a little extra time to pay for services, we work very closely with CareCredit. Our office does offer a payment plan through CareCredit. We offer a 3 month, no interest option as well as a 24, 36, and 48 months extended payment plan options. CareCredits interest rate is 11.9% on extended plans. CareCredit can be reached at 800-839-9078 for further questions.

 

Please be advised that we do charge a fee for all failed and canceled appointments without 24 hours notice

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HIPAA( * mandatory to fill )

I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information.  I understand that this information can and will be used to:

* conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly
* obtain payment from third-party payers (insurance companies)
* conduct normal healthcare services

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information.  I have been given the right to review such Notice of Privacy Practices prior to signing this consent.  I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practice.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment and payment options.  I also understand you are not required to agree to my requested restrictions but if you do agree then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

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