PATIENT INFORMATION


Title: Patient's Name: Date of Birth: Address: Street:City:Zip Code:
Phone No.:
Home phone: Office Phone:
Mobile Phone:
Email Address:
Marital Status:
Patient's Social Security No.:
Patient's Place of Employment: Phone No.:
Employer's Address: Street:City:Zip Code:
Spouse's or Parent's Name:
Spouse's or Parent's Date of Birth:
Spouse's or Parent's Social Security No.:
Place of Employment: Phone No.:
Employer's Address: Street:City:Zip Code:
Student: School: City:State:
In case of Emergency, Please Contact: Phone No.:
Whom may we thank for referring you?:
General Dentist: Location:
Other Consulting Drs.: Location: (Ex: Physicians, Orthodontist, Endodontist, etc.)

INSURANCE INFORMATION


Name of Primary Dental Insurance:
Insured Name: Birthdate:
Name of Primary Medical Insurance: Insured Name: Birthdate:
Name of Secondary Dental Insurance:
Insured Name: Birthdate:
Name of Secondary Medical Insurance: Insured Name: Birthdate:

Please give insurance forms / cards and / or X-rays to the office manager.

OFFICE POLICY REGARDING INSURANCE


Payments: Our office will file insurance claims for our patients as a courtesy at no charge. However, the insurance contract is between the patient and the insurance company. It is your responsibility to know your insurance coverage. Please contact your insurance carrier prior to service being rendered to determine coverage. Due to the variety and complexity of insurance policies, we cannot adequately advise you on these matters. I have read and fully understand the above statement and I am responsible for any and all fees not covered by my plan.

Responsible Party Signature:Date:

OFFICE FINANCIAL POLICY


Thank you for choosing us for your periodontal care. We are committed to your treatment being successful. We invite your participation in your care. We encourage you to ask questions whether they be regarding your treatment, insurance or account. The following is a statement of our Financial Policy that we request that you read, agree to and sign prior to treatment.

PATIENTS WITHOUT INSURANCE COVERAGE - Payment is due at time of service. We accept: Cash, Check, Visa & MasterCard. A 30 day personal periodontal treatment account will be established for you. Monthly statements will be sent informing you of your account status. Payment is expected within one billing cycle. Past due balances will be subject to a 1-1/2 percent per month service charge ($2.00 minimum). If circumstances dictate, arrangements can be made for a payment plan.

PATIENTS COVERED BY INSURANCE - As a service to you, we will submit claims to your insurance company. Please provide us with complete medical and dental insurance information. Payment is required within sixty days of the time services are rendered. Any balance remaining after that time is your responsibility, regardless of insurance. All efforts will be made to help resolve any insurance problems. Please contact our insurance office if you need assistance.

We ask that you pay your estimated share while undergoing active treatment. If you direct your insurance to pay their share of the cost directly to this office, we will give you credit for this anticipated amount. The patient co-pay portion begins to age from the date of service. Upon receipt of the insurance payment, we will reconcile the account, and bill or refund any difference. Any remaining patient portion is due within one billing cycle after receipt of the insurance benefit for the service. Past due balances will be subject to a 1-1/2 percent per month service charge. ($2.00 minimum) If circumstances dictate, arrangements can be made for a payment plan.

DELINQUENT ACCOUNTS - Accounts 90 days past due will be considered delinquent and will be referred to a collection agency or to our attorney for collection.

I have read and fully understand the above. I hereby authorize the release of information for the purpose of payment of insurance benefits and authorize payment directly to Progressive Periodontics & Dental Implants. I authorize the release of any medical information necessary to communicate with other dental or medical offices regarding my treatment. I realize I am responsible for charges not covered by insurance.

Signature:Date:

Our practice complies with Section 146.83 of the Wisconsin Statutes which generally provides that a patient has the right to inspect or receive a copy of the patient's health care records, including radiographs, or have duplicates of the radiographs transferred to another health care provider upon receiving a signed statement describing the request. A reasonable charge for copying records may be applied.

Please select the office you wish to be seen at:

West Bend 1305 Chestnut Street, West Bend, WI 53095
Greenfield 8405 W. Forest Home Avenue, Greenfield, WI 53228