Patient Registration

Personal Data
(Confidential)
Last Name_______________________________________
First Name_________________________MI___________
Date of Birth______________________Sex____________
Soc.Sec.#__________________Marital Status__________

PLEASE ANSWER THE FOLLOWING QUESTIONS
IF YOU HAVE AT LEAST ONE INSURANCE POLICY.
WE ARE REQUIRED TO FURNISH THIS
INFORMATION ON YOUR CLAIM FORM, EVEN IF
YOU DO NOT HAVE ANY OTHER INSURANCE
COVERAGE. THANK YOU.

(Minor, S M D W)

Address_________________________________________
_______________________________________________
City, State, Zip Code_____________________________
_______________________________________________
Phone: Home___________________________________
Patient or Parent Business________________Ext.________
Employer Name__________________________________
Employer Address________________________________
E-Mail Address __________________________________

Billing Information
Person Responsible for your Account:
Guarantor_______________________________________
Date of Birth _____________________________________
Soc. Sec. #_______________________________________
Address (if different)_______________________________
________________________________________________

Referral
Please Indicate How You Learned About Us:
Referred by Another Dentist:________________________
Referred by Another Patient:________________________
Other Source_____________________________________

Are Other Family Members Employed? (Y/N)___________
Name:__________________________________________
Soc. Sec. #_______________________________________
Employer:_______________________________________
Employer Address_________________________________
_______________________________________________

Primary Insurance
Person Insured____________________________________
DOB of Person Insured_____________________________
Relationship of Patient to Insured_____________________
Employer________________________________________
Employer Address_________________________________
Insurance Company_______________________________
Ins. Co. Address__________________________________
Ins. Co. Phone #__________________________________
Subscriber ID #______________Group #_______________
Insurance Type (Med/Dent)__________________________

Secondary Insurance
Person Insured__________________________________
Relationship of Patient to Insured__________________
Employer_______________________________________
Employer Address________________________________
Insurance Commpany_____________________________
Ins. Co. Address_________________________________
Ins. Co. Phone #__________________________________
Group #________________________________________
Subscriber ID #__________________________________
Insurance Type (Med/Dent)________________________

(Yellow Pages, Insurance Co., Location, etc.)

Appointments: A fee will be charged for repeated
failed or canceled appointments without prior

notification of 24 hours.
We realize that
emergencies do occur, so this charge is reserved for
repeated failure to keep appointments. Remember
that once your appointment has been arranged, this
time has been reserved for you!
Insurance Claims: We are pleased that you have
chosen us to assess your periodontal status and we
are here to help you in any way that we can. With
this policy in mind, as a service to our patients, we
have been filing the claims to the carrier. We will
promptly prepare necessary forms or reports to
help you obtain your benefits, given the information
you have provided to us. However, to avoid
misunderstanding regarding your treatment, please
remember that the financial obligations for
treatment rendered are your responsibility. Your
insurance coverage is a contract between you and
your insurance company and not between our office
and your insurance company. Receiving eligible
benefits for your insurance company certainly must
be a shared responsibility. If we must re-submit or
make telephone calls to your insurance carrier to
check on claims, the additional staff time and
expense is not covered in our fees for service. We
ask that you be aware of correspondence from your
insurance company, as you may receive
correspondence before our office receives it. If
your insurance company denies a claim or no
correspondence has been received 30 days after
your appointment, please help us by calling your
insurance company to inquire about the status of
your claim. Be aware that if we receive no
correspondence from your insurance within 30 days
of claim submission, you will be receiving a
statement of your balance with our next billing
cycle.
Patient's understanding, patience and assistance in
dealing with insurance claims make a big difference!
Returned Checks:
returned checks.

There is a $25 fee for all

Collections: All professional services rendered are
charged directly to your account and you are
personally responsible for payment of fees. I agree
to pay a service fee of 1.5% per month on all
money that I owe Dr. Culberson for more than 60
days. In the event that my account is more than 60

days old, I understand that Dr. Culberson will hire
an attorney to obtain a judgement against me. In
that event I will be responsible for paying the
attorney's fee of 33-1/3% of the money that I owe
Dr. Culberson or $150.00, whichever is greater.
I further understand that if I do not pay for Dr.
Culberson's services, my record of nonpayment may
be reported to a credit reporting agency.
TO THE BEST OF MY KNOWLEDGE THE ABOVE
CONFIDENTIAL INFORMATION IS TRUE. IF THE
ABOVE NAMED PATIENT IS A MINOR, I ALSO
GIVE MY PERMISSION FOR TREATMENT.
I
AUTHORIZE
DR.
CULBERSON
TO
USE
"SIGNATURE ON FILE" WHEN PROCESSING MY
INSURANCE CLAIMS. FINALLY, I HAVE READ AND
UNDERSTAND THE ABOVE INFORMATION.
I
AGREE TO ABIDE BY THE CONDITIONS
DESCRIBED IN THIS DOCUMENT.
Signature________________________________________
________________________
Date_____________________________________________
_______________________
Patient Information/Signature Witnessed and Reviewed
by _____________________