Registration

2615 Elk Drive, Ste 3, Minot, ND 58701 Phone: (701) 852-3421 I Fax: (701) 838-1842 I Toll Free: (800) 277-7938 info@northdakotaoralsurgery.com
PATIENT INFORMATION
Date*

MonthDayYear
Date
Patient First Name*
Patient Last Name*
D.O.B*

MonthDayYear
Date
Age*
Gender at Birth*

MaleFemale
Marital Status

SingleMarriedDivorcedWidowed
If Married, Spouse's Name
Patient's Social Security # (required for processing most insurances)
Mailing Address *
City*
State*
Zip Code*
Billing Address (if different than the mailing address)
City
State
Zip Code
Home Phone*
Cell Phone
Email Address
example@example.com
Employer/School (if student)
Work Phone
Emergency Contact Person*

First NameLast Name
Phone*

Dentist

First NameLast Name
City/State
Orthodontist

First NameLast Name
City/State
Primary Care Doctor

First NameLast Name
City/State
Specialty Doctor's (if applicable):
Cardiologist

First NameLast Name
City/State
Oncologist

First NameLast Name
City/State
Nephrologist (kidney)

First NameLast Name
City/State
Other

First NameLast Name
City/State

HIPAA POLICY
A. Family and Friends. It is the office policy to not release confidential medical information regarding your treatment to family members or friends, except for (i) parent(s)/legal guardian(s), (ii) other persons authorized by the patient, (iii) as we may reasonably infer from the circumstances (for example, if you bring a family member or friend into the exam room, we will assume, unless you object, that that person is entitled to receive information regarding your treatment), (iv) in emergency situations, or (v) other as otherwise permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

If you anticipate that you will need or want your medical information to be provided to family members, friends, or caretakers/babysitters, please indicate that below, so that we may best serve you. By signing below, you authorize the following people to receive information regarding your treatment or care.
Spouse

First NameLast Name
Parent(s)

First NameLast Name
Other

First NameLast Name
B. Alternative Communications. You are also entitled to specify alternative, reasonable means of communication if you do not wish to be contacted by us in a certain way.
I hereby request the following means of contact only
C. HIPAA Acknowledgement. By signing below, I acknowledge that I have read and understand North Dakota Oral Surgery & Dental Implant Center's Notice of Privacy Practices. I have been provided with a copy of these policies if requested. You may contact me and leave messages by phone, mail, or email.
Printed Name*

First NameLast Name
Signature*

Clear
(Patient (if at least 18) /Parent/Legal Guardian)
Date*

MonthDayYear
Date

OFFICE POLICY: PAYMENT FOR TREATMENT
I understand that payment is expected at the time services are rendered. I will pay according to method indicated (please check one):*

1. I will pay all fees at the time of treatment by cash, debit card, or credit card (Visa®, Mastercard®, Discover®, American Express®), or CareCredit® financing. (you should check this box if you do not have insurance)2. (For insurance coverage) I will pay the amount quoted to me as my estimated "down payment" at the time of treatment with the following agreement:
This office is not contracted with all insurance companies. Your insurance coverage is a contract between you and your insurance company to assist you in paying for services. If we have the necessary information, we will be glad to assist you in the submission of your claim, but the payment of your account is ultimately your responsibility. Your insurance company may not pay for some or all of the services you receive. Insurance companies only pay for "covered" items or services when their unique rules are met. Since insurance companies will not provide us with a list of these rules, we are unable to inform our patients about services that may or may not be covered under the patient's particular plan. If payment for services is denied by your insurance company, paid at a lesser fee than ours, or determined "not medically necessary" according to their unique policy provisions, you are still responsible for any remaining balance. Any fees left unpaid by your insurance are payable by you in full 60 days from the initial date of treatment. Please remember that insurance coverage is not a guarantee of payment for your services. Since insurance plans vary widely in what they will or will not pay for and how much they will pay for services, the amount quoted as your "down payment" should not be relied upon to be your total balance due. We can only estimate your coverage and co payments and cannot be held responsible for your insurance company not paying as much as estimated. When treatment is not urgent, submission of anticipated treatment to your insurance company for a pre determination of your benefits can be done before scheduling the treatment. Although this may provide additional information regarding the expected payment by your insurance, this too is not a guarantee of payment by your insurance company.
Insurance Pre-Authorization Request: If you would like a pre-determination sent to your insurance company before scheduling treatment, please inform a practice coordinator. Please note this may delay your treatment due to insurance company processing times and check here:

Yes, please request a pre-determination from my insurance company before scheduling treatment.No, I do not want to wait for the processing of a pre-determination from my insurance. I would like to proceed with treatment as soon as possible.Not applicable
There is a service charge of 1.5% per month assessed on any account balance over 60 days with a minimum service charge of $1.00 per month.

I have read and I understand the terms of payment as outlined above. I agree that in the event I default and do not make payment in accordance with the terms indicated above, my account will be transferred to a collection agency, and I will be responsible for the costs of collection, including reasonable attorney's fees. Further, I understand that I will be responsible for any other fees associated with the collection of payment (such as, but not limited to, exact fees charged by a financial institution).
Printed Name*

First NameLast Name
Signature*

Clear
(Patient (if at least 18)/Parent/LegalGuardian)
Date*

MonthDayYear
Date
Should be Empty:

PATIENT INFORMATION

HIPAA POLICY

MEDICARE INSURANCE PLANS

PRIMARY DENTAL INSURANCE

SECONDARY DENTAL INSURANCE

PRIMARY MEDICAL INSURANCE

SECONDARY MEDICAL INSURANCE

PATIENT OR LEGAL GUARDIAN'S SIGNATURE

OFFICE POLICY: PAYMENT FOR TREATMENT

There is a service charge of 1.5% per month assessed on any account balance over 60 days with a minimum service charge of $1.00 per month.