Form - Dental Registration - Market Street Dental

Dental Registration and History

Step 1 of 7

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Patient Name*
PrefixFirstLastSuffix
Patient Address*
Street AddressCityStateZip Code
Email Address
Enter EmailConfirm Email
Date of Birth*
MM
DD
YYYY
Last four digits of your SSN*
Gender*
Marital Status*
- Single
- Married
- Divorced
- Widowed
- Minor
- Separated
- Partnered
Occupation*

Who is responsible for this account?*
FirstLast
Relationship to Patient
Leave blank if the patient is responsible for the account.
Insurance Carrier*
Insurance Group Number or ID*
Is the patient covered by additional insurance?*
- Yes
- No
Secondary Party's Name
FirstLast
Secondary Insurance Carrier
Secondary Group Number or ID
Please read the following carefully.*
- I certify that I, and/or my dependent(s), have insurance coverage with the companies listed above and assign directly to Market Street Dental or Rio Verde Dental all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all changes whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
  
  The above-named dentist may use my health care information and may disclose such information to the above-named insurance companies and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date that this form was electronically submitted.

Home Phone Number*
Work Phone Number
Cell Phone Number
Phone Number for Spouse
Best time to reach you?*
In Case of Emergency, please contact*
FirstLast
Please consider specifying someone who does not live in your household.
Relationship to Patient*
Emergency Contact Phone Number*

HIPPA Consent Form
Market Street Dental Consent for use and Disclosure of Health Information.
Please read the following statements
Purpose of Consent
By signing this form, you will consent to our use and disclosure ofyour protected health information to carry out treatment, payment activities, and healthcare operations. Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description ofour treatment, payment activities, and healthcare operations, ofthe uses and disclosures we may make ofyour protected health information, and ofother important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:

Right to Revoke
You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation ofthis Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.
Electronic Submission of Data*
- By electronically submitting my information, I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by submitting this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.
On Behalf of the Patient
If this consent is signed by a personal representative on behalf of the patient, complete the following:
Personal Representative's Name
PrefixFirstLastSuffix
Relationship to Patient

Patient Responsibility Agreement
By checking the boxes below I am agreeing to the following statements.*
- I fully understand that I am financially responsible for any and all charges incurred regardless ofinsurance. (The actual charges allowed for the specific policies and procedures of the dental insurance planes) of which you are a member often determine the services you receive.)
*
- I understand that co-pays are to be paid at the time of the appointment.
*
- I understand that payment of my estimated portion of services rendered is due at the time of service.
*
- I understand that if Dr. Kopsky is not a participant in my insurance plan, I will be responsible for payment on the day of service, and that Dr. Kopsky will file my claim with my insurance plan for my eventual reimbursement to the extent that I am eligible for reimbursement.
*
- I understand that dental insurance many not pay my entire bill and that I will receive a bill for the portion of the fees that are my responsibility. I understand that if I have a balance due that is more than 30 days old, I will be charged a monthly fee of 1.5% (18% annually) on this balance.
Authorization to pay benefits*
- I hereby authorize payment directly to Dr. Kopsky the benefits, if any, otherwise payable to me. This agreement shall remain in full force and effect until written notice to the contrary is provided by the undersigned. I hereby acknowledge that I will be personally responsible for payment of assigned insurance benefits when not paid within sixty (60) days of filing a completed claim.
Authorization for release of dental records*
- I authorize the release of any dental information necessary to process my claims.

Form – Dental Registration

Dental Registration and History

Step 1 of 7

HIPPA Consent Form

Please read the following statements

Purpose of Consent

Right to Revoke

On Behalf of the Patient

Patient Responsibility Agreement