NEW PATIENT FORM

Dental Insurance
I have Dental Insurance*
- Yes
- No
Carriers*
- Primary
- Secondary
Primary Carrier
Policy Holder*
First Last
Birth Date*
ID / Social Security #*
Insurance Company*
Phone*
Group Policy #*
Employer*
Address*
Street Address City State ZIP Code
Secondary Carrier
Policy Holder*
First Last
Birth Date*
Social Security #*
Insurance Company*
Phone*
Group Policy #*
Employer*
Address*
Street Address City State ZIP Code
I authorize the release of treatment information to my insurance company for payment of benefits on my behalf. I also assign any insurance benefits to Marguerite P. Myers, D.D.S. unless I pay in full at the time of my treatment.
Date*
Signature*

Acknowledgement of Receipt of Notice of Privacy Practices
I acknowledge that I have received a copy of Dr. Peggy Myers Office's "Notice of Privacy Practices" This notice describes how Dr. Peggy Myers Office may use and disclose my health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected health information. This notice also informs the patient that Dr. Peggy Myers Office will not release any personal information for marketing purposes, or to related organizations. This notice takes effect April 14, 2003, and will remain in effect until we replace it.
Name
First Last
Date*
Signature*

Patient Information