| Periodontics
Northwest Patient
Registration |
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| Patient's Information: | ||||
| First
name
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| E-mail |
Today's
Date: |
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| Address |
City: |
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| State
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Zip:
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| Home
Phone |
Work
phone: |
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| Cell
Phone |
Date
of birth |
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SS# |
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| Marital
Status |
Employer |
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| Who referred you to our office? | ||||
| In
case of emergency
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| Spouse's Name |
Phone/Cell#
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| Other
than spouse |
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Phone/Cell#
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| Insurance Information | ||||
| Primary |
Secondary |
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| Subscriber's
Name |
Subscriber's
Name |
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| Subscriber's
S.S.# |
Subscriber's
S.S.# |
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| Subscriber's date of birth |
Subscriber's
date of birth |
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| Insurance
Company |
Insurance
Company |
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| Ins
.Co. Address
Ins
.Co. Address
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| City, St., Zip City, St., Zip | ||||
| Phone# |
Phone# |
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| Authorization I authorize Periodontics Northwest and my dentist(s)/physician(s) to release any and all medical or dental information for evaluation, treatment, and any anticipated care. The above information has my release to forward to my insurance carrier for purposes of claims, administration and evaluation, utilization review and financial audit. this authorization remains valid and effective from the signature date until revoked in writing. I hereby authorize payment to the above named dentists of the group insurance benefits, otherwise payable to me. but not to exceed the charges submitted. I understand that I am financially responsible for any charges (including collection fees); and that I am responsible for knowledge of my insurance program and limitations. Interest accrues 90 day after services are rendered. I understand that I may request a copy of this form. I have read this authorization and understand its contents. |
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| Signed
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Date |
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