New Patient Forms

Patient Registration Form

Responsible Party If Different from Above

Insurance Policy

please provide subscriber address if different from above

Financial Agreement

• ALL ACCOUNTS ARE DUE AND PAYABLE AT TIME OF SERVICE.
• Patients with insurance: The PATIENT is responsible for the ESTIMATED non-covered portion of, procedures and/or deductibles at the time of the service. We cannot and do not guarantee payment from your Insurance company. If a balance is remaining after insurance processes and pays for a claim, the patient is responsible for the remaining portion in full.
• Billing Charges: All accounts with a balance past 30 days may be subject to a $25.00 per month billing charge.
• Missed Appointment Charges: Missed appointments with less than 48 hours’ notice may be subject to a $55.00 charge.
• Parents not accompanying their child to an appointment must make PRIOR arrangements for payment (cash, check, or credit card authorization.
• I HAVE READ AND AGREE TO THE ABOVE FINANCIAL POLICY

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Notice Of Privacy Practices

I understand that, under 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 multiple healthcare providers who may be involved in that treatment directly and indirectly.
• Obtain payment from third- party payers.
• Conduct normal healthcare operations such as quality assessments and physician certifications.

I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. 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 above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operation. 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.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

I give permission for the following people to inquire about my treatment, diagnosis, or accounts.

Assignment of Benefits Agreement Form

I hereby assign all Rights and dental benefits, to include major dental benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including Medicaid, private insurance and any other health/medical plan, to issue payment directly to Yost Family Dental

Authorization to Release Information

I hereby authorize Yost Family Dental To:

1. RELEASE any information necessary or requested to insurance carriers, including Medicaid, regarding my (and or my dependents) illness and treatment and other personal information that may be requested by insurance.
2. PROCESS insurance claims generated in the course of examination or treatment; appeal insurance payments or denials on my behalf.
3. ALLOW a photocopy of my signature and this form to be used to process insurance claims and fulfill any other request from insurance for the period of the lifetime. This order will remain in effect until revoked by me in writing.

I have requested dental services from Yost Family dental on behalf of myself and/or my dependents, and understand by making this request that I become fully financially responsible regardless of insurance reimbursement for any and all charges incurred in the course of treatment.

I HAVE READ AND UNDERSTAND THE ABOVE TERMS AND CONDITIONS. I AUTHORIZE MY INSURANCE COMPANY TO PAY MY DENTAL BENEFITS DIRECTLY TO THE DOCTOR.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Eaglesoft Medical History Form

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.