New Patient Forms Step 1 of 17 5% PERSONAL INFORMATIONPatient Name First Last How do you prefer to be addressed? Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country GenderMaleFemalePrefer Not to AnswerMarital StatusSingleMarriedDivorcedWidowedSocial Security Number Date of Birth Month Day Year Phone - MobilePhone - WorkPhone - HomeEmail Address Enter Email Confirm Email Preferred Method of ContactPhone - Mobile - VOICEPhone - Mobile - TEXTPhone - WorkPhone - HomeE-Mail EMPLOYMENT INFORMATIONOccupation Employer Employer's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Is someone other than the patient responsible for payment? No Yes RESPONSIBLE PARTY PERSONAL INFORMATIONName of Responsible Party First Last Relationship to Patient Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Social Security Number Date of Birth Month Day Year Phone - Mobile*Phone - WorkPhone - HomeEmail Address Enter Email Confirm Email Preferred Method of ContactPhone - Mobile - VOICEPhone - Mobile - TEXTPhone - WorkPhone - HomeE-Mail PRIMARY INSURANCE INFORMATIONPolicy Holder's Name First Last Relationship to Patient Social Security Number Date of Birth Month Day Year Employer Employer's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How would you like to provide your primary insurance information? I will upload an image of my insurance card I will type in my provider information manually PRIMARY INSURANCE INFORMATIONUpload Image of Insurance CardMax. file size: 512 MB. PRIMARY INSURANCE INFORMATIONName of Insurance ProviderAdvanticaAetnaAffinity Dental Health PlanAffordable Family Health ServicesAflacAFTRA Health & Retirement FundsAIGAlameda Alliance for HealthAltus DentalAlwaysCareAmerican Dental Professional ServicesAmeriGroupAmeriplanAmeritasAnthem Blue Cross Blue ShieldAnthem Blue Cross of CaliforniaArkansas Blue Cross Blue ShieldAssurant Employee BenefitsATRIO Health PlansAvesisBanner HealthBest Choice PlusBest Life And HealthBlue Care Network of MichiganBlue Choice Health PlanBlue Cross Blue ShieldBlue Cross Blue Shield Federal Employee ProgramBlue Cross Blue Shield of AlabamaBlue Cross Blue Shield of ArizonaBlue Cross Blue Shield of Florida (Florida Blue)Blue Cross Blue Shield of GeorgiaBlue Cross Blue Shield of IllinoisBlue Cross Blue Shield of KansasBlue Cross Blue Shield of Kansas CityBlue Cross Blue Shield of MassachusettsBlue Cross Blue Shield of MichiganBlue Cross Blue Shield of NebraskaBlue Cross Blue Shield of New MexicoBlue Cross Blue Shield of North CarolinaBlue Cross Blue Shield of North DakotaBlue Cross Blue Shield of OklahomaBlue Cross Blue Shield of Rhode IslandBlue Cross Blue Shield of South CarolinaBlue Cross Blue Shield of TennesseeBlue Cross Blue Shield of TexasBlue Cross Blue Shield of Western New YorkBlue Cross of IdahoBlue Cross of Northeastern PennsylvaniaBlue Shield of CaliforniaBlue Shield of Northeastern New YorkBoston UniversityBridgeSpanBridgeway Health SolutionsBrokers National Life InsuranceCareFirst Blue Cross Blue ShieldCareingtonCareSourceCBA BlueCignaCMDP (Comprehensive Medical and Dental Program)Commonwealth CareCommunity First Health PlansCompBenefitsConcentraConnection DentalCoventry DentalCulinary Health FundDAKOTACAREDearborn NationalDelta DentalDenCapDental Benefit ProvidersDental Care PlusDental Network of AmericaDental SelectDentalSaveDentaQuestDentegraDentemaxDenti-CalDenticareDeseret MutualDevon Health ServicesDominion DentalEasy Choice Health Plan (California)ElderplanEmblemHealthEMI HealthEmpire Blue Cross Blue ShieldEncore DentalExcellus Blue Cross Blue ShieldFallon Community Health Plan (FCHP)Fidelio DentalFidelis Care (NY)First AmeritasFirst Choice HealthFirst Dental HealthFirst Health (Coventry Health Care)Florida Blue: Blue Cross Blue Shield of FloridaGE Consumer FinanceGEHA Dental PlansGHIGolden RuleGolden West DentalGuardianGWH-Cigna (formerly Great West Healthcare)Hawaii Dental Service (Delta Dental)Health ChoiceHealth NetHealth Plan of NevadaHealthFirst (NY-NJ)HealthplexHIPHorizon Blue Cross Blue Shield of New JerseyHumanaIHC Group (Independent Holding Company)J.J. Stanis and Company, Inc.Kansas City LifeLaw Enforcement Health Benefits (LEHB)Liberty DentalLifeMapLifeWiseLincoln Financial GroupMAMSIManatee Your Choice Health PlanMaricopa Health PlanMassHealthMCNA DentalMedicaMedicaidMedical MutualMercy CareMeritain HealthMesa Dental PlanMetLifeMetro PlusModa HealthMolina HealthcareMutual of OmahaNational Pacific DentalNationwideNippon Life BenefitsNovaNetOneNet DentalOxford (UnitedHealthcare)PacificSource Health PlansParamount HealthcarePeach State Health PlanPeachCare for KidsPhysicians Plus Insurance CorporationPiedmont Community HealthPreferred Health SystemsPremera Blue CrossPremier AccessPrincipal Financial GroupPriority HealthPrudential DentalQuality Plan AdministratorsRayantRegence Blue Cross Blue ShieldReliance StandardSafeGuardSaint Mary's Health PlansSecurity LifeSeleDentSeven CornersSolsticeSound Health & Wellness TrustSoutheast Dental PlanStarDentStarmarkStratoseSun Life FinancialSuperior Dental CareTDA (Total Dental Administrators)Teachers Health TrustTexas Children's Health PlanThe StandardTricare Dental ProgramTriple-S Salud: Blue Cross Blue Shield of Puerto RicoTrustMarkUniCareUnionUnison Health PlanUnited ConcordiaUnitedHealthcareUnitedHealthcare Community PlanUnitedHealthcare OxfordUniversity Family CareUPMC Health PlanVision Plan of AmericaWashington Dental Service (Delta Dental)WellcarePolicy # Group # SECONDARY INSURANCE INFORMATIONDo you carry secondary insurance? No Yes SECONDARY INSURANCE INFORMATIONPolicy Holder's Name First Last Relationship to Patient Social Security Number Date of Birth Month Day Year Employer Employer's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How would you like to provide your secondary insurance information? I will upload an image of my insurance card I will type in my provider information manually SECONDARY INSURANCE INFORMATIONUpload Image of Insurance CardMax. file size: 512 MB. SECONDARY INSURANCE INFORMATIONName of Insurance ProviderAdvanticaAetnaAffinity Dental Health PlanAffordable Family Health ServicesAflacAFTRA Health & Retirement FundsAIGAlameda Alliance for HealthAltus DentalAlwaysCareAmerican Dental Professional ServicesAmeriGroupAmeriplanAmeritasAnthem Blue Cross Blue ShieldAnthem Blue Cross of CaliforniaArkansas Blue Cross Blue ShieldAssurant Employee BenefitsATRIO Health PlansAvesisBanner HealthBest Choice PlusBest Life And HealthBlue Care Network of MichiganBlue Choice Health PlanBlue Cross Blue ShieldBlue Cross Blue Shield Federal Employee ProgramBlue Cross Blue Shield of AlabamaBlue Cross Blue Shield of ArizonaBlue Cross Blue Shield of Florida (Florida Blue)Blue Cross Blue Shield of GeorgiaBlue Cross Blue Shield of IllinoisBlue Cross Blue Shield of KansasBlue Cross Blue Shield of Kansas CityBlue Cross Blue Shield of MassachusettsBlue Cross Blue Shield of MichiganBlue Cross Blue Shield of NebraskaBlue Cross Blue Shield of New MexicoBlue Cross Blue Shield of North CarolinaBlue Cross Blue Shield of North DakotaBlue Cross Blue Shield of OklahomaBlue Cross Blue Shield of Rhode IslandBlue Cross Blue Shield of South CarolinaBlue Cross Blue Shield of TennesseeBlue Cross Blue Shield of TexasBlue Cross Blue Shield of Western New YorkBlue Cross of IdahoBlue Cross of Northeastern PennsylvaniaBlue Shield of CaliforniaBlue Shield of Northeastern New YorkBoston UniversityBridgeSpanBridgeway Health SolutionsBrokers National Life InsuranceCareFirst Blue Cross Blue ShieldCareingtonCareSourceCBA BlueCignaCMDP (Comprehensive Medical and Dental Program)Commonwealth CareCommunity First Health PlansCompBenefitsConcentraConnection DentalCoventry DentalCulinary Health FundDAKOTACAREDearborn NationalDelta DentalDenCapDental Benefit ProvidersDental Care PlusDental Network of AmericaDental SelectDentalSaveDentaQuestDentegraDentemaxDenti-CalDenticareDeseret MutualDevon Health ServicesDominion DentalEasy Choice Health Plan (California)ElderplanEmblemHealthEMI HealthEmpire Blue Cross Blue ShieldEncore DentalExcellus Blue Cross Blue ShieldFallon Community Health Plan (FCHP)Fidelio DentalFidelis Care (NY)First AmeritasFirst Choice HealthFirst Dental HealthFirst Health (Coventry Health Care)Florida Blue: Blue Cross Blue Shield of FloridaGE Consumer FinanceGEHA Dental PlansGHIGolden RuleGolden West DentalGuardianGWH-Cigna (formerly Great West Healthcare)Hawaii Dental Service (Delta Dental)Health ChoiceHealth NetHealth Plan of NevadaHealthFirst (NY-NJ)HealthplexHIPHorizon Blue Cross Blue Shield of New JerseyHumanaIHC Group (Independent Holding Company)J.J. Stanis and Company, Inc.Kansas City LifeLaw Enforcement Health Benefits (LEHB)Liberty DentalLifeMapLifeWiseLincoln Financial GroupMAMSIManatee Your Choice Health PlanMaricopa Health PlanMassHealthMCNA DentalMedicaMedicaidMedical MutualMercy CareMeritain HealthMesa Dental PlanMetLifeMetro PlusModa HealthMolina HealthcareMutual of OmahaNational Pacific DentalNationwideNippon Life BenefitsNovaNetOneNet DentalOxford (UnitedHealthcare)PacificSource Health PlansParamount HealthcarePeach State Health PlanPeachCare for KidsPhysicians Plus Insurance CorporationPiedmont Community HealthPreferred Health SystemsPremera Blue CrossPremier AccessPrincipal Financial GroupPriority HealthPrudential DentalQuality Plan AdministratorsRayantRegence Blue Cross Blue ShieldReliance StandardSafeGuardSaint Mary's Health PlansSecurity LifeSeleDentSeven CornersSolsticeSound Health & Wellness TrustSoutheast Dental PlanStarDentStarmarkStratoseSun Life FinancialSuperior Dental CareTDA (Total Dental Administrators)Teachers Health TrustTexas Children's Health PlanThe StandardTricare Dental ProgramTriple-S Salud: Blue Cross Blue Shield of Puerto RicoTrustMarkUniCareUnionUnison Health PlanUnited ConcordiaUnitedHealthcareUnitedHealthcare Community PlanUnitedHealthcare OxfordUniversity Family CareUPMC Health PlanVision Plan of AmericaWashington Dental Service (Delta Dental)WellcarePolicy # Group # HEALTH HISTORYDo you have, or have you had any of the following conditions? (Please check all that apply) Are you required to Pre-medicate before dental treatment? Blood Problems (Anemia) Blood transfusion Heart problems Heart murmur, mitral valve prolapse, heart defect Heart Pacemaker Stroke Bone or joint problems Artificial joints or valves High blood pressure Low blood pressure Tuberculosis or other lung problems Kidney disease Hepatitis, jaundice or other liver disease Diabetes TYPE 1 or TYPE 2 Epilepsy or Neurological disorders Thyroid problems Arthritis Herpes or cold sores AIDS or HIV Cancer or Tumor Abnormally heavy bleeding after any surgery Hayfever or sinus trouble Allergies Asthma Other (please specify) HEALTH HISTORYAre you allergic to, or have you reacted adversely to any of the following? Latex Penicillin or other antibiotics Local anesthetics Codeine or other narcotics Sulfa drugs Barbiturates, sedatives, or sleeping pills Aspirin Other (please specify) HEALTH HISTORYAre you taking any of the following? Aspirin Anticoagulants (blood thinners e.g., Coumadin) Local anesthetics Antibiotics or sulfa drugs High blood pressure medicine Antidepressants or tranquilizers Insulin other diabetes drugs Nitroglycerin Cortisone or other steroids Osteoporosis (bone density) medicine Natural supplements Other (please specify) HEALTH HISTORYDo you smoke, vape or use tobacco?YesNoFemale patients, please check all that apply Are you pregnant or plan to become pregnant Are you taking hormones or contraceptives Name of your primary medical physician Primary medical physician contact (phone or email) STATEMENT OF PRIVACY PRACTICESOur office is dedicated to protecting the privacy rights of our patients and the confidential information entrusted to us. It is a requirement of this practice that every employee receive appropriate training and is dedicated to the principal concept that your health information shall never be compromised. We may, from time to time, amend our privacy policies and practices but will always inform you of any changes that might affect your our obligations and your rights. Protecting Your Personal Healthcare Information We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and Accountability Act and the state of Washington. This includes issues relating to your treatment, payment, and our healthcare operations. Your personal health information will never be otherwise given or disclosed to anyone – even family members – without your consent or written authorization. You, of course, may give written authorization for us to disclose your information to anyone you choose, for any purpose. Our offices and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality, integrity, and access to your records is always protected. Our privacy policy and practices apply to all former, current, and future patients, so you can be confident that your protected health information will never be improperly disclosed or released. Collecting Protected Health Information (PHI) We will only request personal information needed to provide our standard of quality health care, implement payment activities, conduct normal health practice operations, and comply with the law. This may include your name, address, telephone number(s), Social Security Number, employment data, medical history, health records, etc. While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law. Disclosure of your Protected Health Information As stated above, we may disclose information as required by law. We are obligated to provide information to law enforcement and governmental officials under certain circumstances. We will not use your information for marketing or fund-raising purposes without your written consent. We may use and/or disclose your health information to communicate reminders about your appointments including voicemail messages, answering machines, and postcards unless you direct us otherwise. We will never use, disclose, sell, or otherwise allow access to your personal, protected information in exchange for or receipt of financial remuneration. Any breach in the protection of your personal health information, including unauthorized acquisition, access, use, or disclosure, will be fully investigated, addressed, and mitigated as established by the HIPAA Privacy Breach Notification Rule. You have a right to and will be provided all information relating to any breach involving your personal PHI. Your Rights as our Patient You have a right to request copies of your healthcare information; to request copies in a variety of formats; and to request a list of instances in which we, or our business associates, have disclosed your protected information for uses other than stated above. All such requests must be in writing. We may charge for your copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately. You can also notify the U.S. Department of Health and Human Services. If you’d like a full and complete copy of our Statement of Privacy Practices, please ask at the front desk. I acknowledge that I have reviewed the Statement of Privacy Practices for the offices of Prestige Dental. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility. Prestige Dental reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.* I have read and agree to the STATEMENT OF PRIVACY PRACTICES ADDITIONAL DISCLOSURE AUTHORIZATIONIn addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare Information (PHI) to the person(s) identified below. I understand that the default option is “NO - do not disclose”. Without explicitly checking “YES” next to a specific individual(s) below, PHI cannot be shared with anyone unless otherwise allowed by HIPAA rules. Select All Spouse Only Any Member of my immediate family (e.g. Children, Children’s Spouses, etc.) Any Member of my extended family (e.g., Parents, Grandchildren, etc.) Other (Please indicate identity below) Name of individual authorized for PHI disclosure First Last FINANCIAL POLICYWelcome to Prestige Family and Cosmetic Dentistry, where our team of dental professionals is committed to making your every visit relaxing and productive. Please sign this document to acknowledge your understanding of our Financial Policy. Appointment Cancellations WE UNDERSTAND THAT SOMETIMES YOU WILL NEED TO RESCHEDULE YOUR TREATMENT. APPOINTMENT CANCELLATIONS ARE ONLY ACCEPTED DURING BUSINESS HOURS BY PHONE. WE REQUIRE 2 BUSINESS DAYS’ NOTICE TO CHANGE OR CANCEL AN APPOINTMENT AND 3 BUSINESS DAYS’ NOTICE FOR SATURDAY APPOINTMENTS TO AVOID A CANCELLATION FEE. WITHOUT THIS ADVANCE NOTICE, YOU WILL BE CHARGED $50 PER HALF HOUR OF MISSED APPOINTMENT TIME. Dental Insurance You have a contract with your dental insurance company; we are not a party to that contract. While we do our best to obtain accurate information from your insurance company on your behalf, it is ultimately your responsibility to understand your policy and its limitations. Regardless of whether we are in network for your insurance, the final responsibility for all charges associated with your treatment lies with you – the patient. Estimates We solicit an estimate from your dental insurance company, that you should consider a guideline until final insurance payment is received and your account has been reconciled. We make every effort to provide accurate estimates, but our office can make no guarantee that insurance payments will match our estimates. Claims We promptly submit a claim to your insurance company after treatment. Any claim that is unpaid is billed directly to you. Predeterminations At your request, we will gladly process your predetermination, but please be aware that predeterminations are not guarantees of payment. Payment Is Due At the Time of Service You may have an out-of-pocket portion (coinsurance) which is determined by information and percentages provided by your insurance company. Your coinsurance portion will be presented in an estimate prior to scheduling your appointment. A deposit or prepayment is required to hold an appointment and is calculated based on the treatment scheduled, duration of appointment, time and day of the week. Service Charges Accounts which are 60 days past due are assessed a monthly finance charge equivalent to an annual rate of 10.0%. Outstanding balances and applicable fees will be forwarded to a collection agency after 120 days of no response. Services Not Covered You, or the party responsible for your account, agree to provide payment in full for procedures performed in this office, including any treatment not covered by your dental insurance. We accept Visa, MasterCard and cash as forms of payment. A processing fee of 2.5% will be added to all credit transactions.I acknowledge that I have reviewed the Financial Policy for the offices of Prestige Dental. The Financial Policy describes my responsibilities with respect to payments for services rendered. The Financial Policy is also posted in the facility. Prestige Dental reserves the right to change the practices currently described in the Financial Policy. If practices change, I will be offered a copy of the revised Financial Policy at the time of my first visit after the revisions become effective. I may also obtain a revised Financial Policy by requesting that one be mailed or otherwise transmitted to me.* I have read and agree to the FINANCIAL POLICY By providing my signature below, I certify that all the information (including medical, personal, and insurance records) is true and complete. I give my full permission to Prestige Dental to check and verify my credit and/or employment history. I further understand that Prestige Dental will assist me in filing my claims, but the insurance coverage I have for dental services can vary and will depend on my insurance plan. I understand that I am responsible for all fees and services. Because Prestige Dental personnel often provide continuing education to other doctors, I give my permission to use my photos for educational purposes. If the patient is a minor, as the responsible party I give permission, in my absence, to provide examinations, dental cleanings and necessary x-rays as part of routine care for this patient. 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