Patient Registration Form

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Patient Registration Form
___________________________________________________________________________________________________
Patient Information
First Name: _________________ Last Name: __________________________________
Address: ________________________________________________________________________
City, State, ZIP Code: ______________________________________________________________
Home Phone: _____________________
Cell Phone: ______________
Work Phone:________________
E-Mail Address: ____________________________
Birth Date: _______________
Social Security #: ______________________
Male
Female
Marital Status:
Single
Married/ Domestic Partnership
Divorced
Widowed
Referred to us by:
another patient ________________
Insurance
Other__________________
____________________________________________________________________________________________________
Insurance Information
No Insurance
Insured:
Self
Spouse/ Partner
Parent
Name of Insured: __________________________________________________
Birth Date: _______________
Social Security #: ______________________
Employer: _____________________
Insurance Carrier: __________________
Group #: ___________________
Carrier ID #: _________________
Patient Responsibility
Dr. Backiel and Associates recommend that all patients verify eligibility and benefits with their insurance company prior to
receiving dental services. While we make every effort to acquire all information about your dental insurance coverage based
on the information you provide us, we are not responsible for informing patients of insurance coverage. Please be aware that
not all dental services are covered by all insurance carriers. Non-covered procedures must be paid in full at the time services
are received.
If your insurance company denies payment, the guarantor of the account (you) will become responsible for payment. Once
the balance is deemed a patient’s responsibility, Dr. Backiel and Associates will bill you directly and the balance is requested
in full upon receipt of the statement.
Time has been specifically reserved for your dental appointment, procedure or treatment. Please call at least 48 hours ahead
of time if you must cancel an appointment. There is a $75 charge if you fail to show up for a scheduled appointment or
cancel with less than 48 hours notice.
I have received a copy of the notice of privacy practice as required by the Health Insurance Portability and Accountability
Act of 1996 ( HIPPA). To the best of my knowledge, the questions on this form and the medical history have been
accurately answered.
Patient Signature:___________________________________
Date:___________________

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