Coyne Oral Surgery -- Patient History Form

NO INSURANCE COVERAGE - PAYMENT IS DUE AT THE TIME OF SERVICEINSURANCE COVERAGE FOR PATIENT - PLEASE PROVIDE INSURANCE CARD
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I UNDERSTAND AND ACKNOWLEDGE THAT I AM FINANCIALLY RESPONSIBLE FOR THE SERVICES PROVIDED, REGARDLESS OF INSURANCE COVERAGE. COYNE ORAL SURGERY RESERVES THE RIGHT TO REFER UNPAID PAST DUE BALANCES TO THIRD PARTIES FOR COLLECTION. IN THE EVENT THAT ANY PAST DUE BALANCE IS PLACED WITH A THIRD PARTY, I AGREE TO PAY ANY COSTS OF SUCH COLLECTION INCLUDING AGENCY FEES, LEGAL/ATTORNEY FEES, AND COURT COSTS.

IF YOU CANCEL A SCHEDULED SURGERY WITHIN 24 HOURS OF PROCEDURE, A NON-REFUNDABLE FACILITY FEE WILL APPLY.

I UNDERSTAND AND ACKNOWLEDGE THAT I READ THE NOTICE OF THE PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION, AND I AUTHORIZE THE DOCTORS OF THIS OFFICE TO RELEASE MY RECORDS.
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