Date____________________                             Patient SS#_________________________

 

Patient Name_________________________________________________________________

                                      _{Last                                                             Fiirst                                                          Middle Initial}

 

Address______________________________________________________________________

      _{P.O. Box not acceptable                                                             City                   State                         Zip___}

 

Email Address ________________________________      Sex:    M          F        __________

                                                                                                    _{Circle choice                 Age}                    

Birthdate______________________      Occupation:_________________________________

 

Married    Widowed    Single    Minor  Divorced  Home Phone________________Cell_________________

                               _{Circle choice}                 

Employer orSchool___________________________           Work Phone ___________________

 

Spouse/Partner’s Name________________________           Birthdate_____________________

 

Ss#of Spouse_____________________      Spouse Employer____________________________

 

Whom may we thank for referring you?______________________________________________

 

In case of Emergency we should call:________________________Phone___________________

 

Who is responsible for payment of the account:________________________________________

 

Relationship to Patient:________________Primary Dental Ins. CO Name______________________

 

Ins Group #________________________ Subscriber ID _________________________________

 

Ins Phone #________________________  Is patient covered by additional ins?       NO      Yes        

Secondary Dental Ins. CO Name______________________Subscriber Name__________________

 

Ins Group #________________________ Subscriber ID _________________________________

 

Ins Phone #________________________ Subscriber Birthdate_____________________________

 

Assignment and Release

I certify that I, and or my dependents have insurance coverage and assign directly to Dr. G’Sell all insurance payments, if any, otherwise payable to me for services rendered.

I acknowledge my understanding that I am financially responsible for all charges whether or not paid by insurance.  I authourize the use of my signature on all insurance submissions.

Dr. G’Sell may use my health care information and may disclose such information to the above named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This authorization is in effect for any insurance plan I currently have.

I understand that payment is due at the time of treatment unless otherwise arranged by the office of Dr. G’Sell.  I understand that a billing fee may be applied to any payment arrangement I fail to honor.

 

_________________________________________       Date______________________

_Signature

_________________________________________  Relationship to patient_____________

 

_{Printed name}