Lester M. Lubitz, D.D.S.

Richard E. Lamping, D.D.S.

On-Line Forms

Patient Information Sheet

Title:(Mr.,Mrs.,Ms.,Dr.)First Name: _______________________________________________

Middle Initial:______Last Name:________________________________________________

Sex:

Male

Female

 Date of Birth:______________Age:_______Soc.Sec.#_____________________________  

 Address:

Street:__________________________________City:_____________________________

State:_______________Zip:_________________

Home Phone:__________________BusinessPhone:___________________Ext._______

Married Divorced Single Widow Legally Separated

 

 

 

 

 Physician:______________________Dentist:_____________________

Referred By:_____________________Have you or any family member been seen

here before?_____________________________________________

 

 Who is responsible for your account? Self Spouse Mother

Father _____________________

Responsible Persons Information:

Name:________________________________Soc.Sec.#________________

Home Phone:( ___)__________________Work Phone:(___)______________

Street:______________________________City:_______________________

State:_________________Zip:______________

Employer:__________________________________Tel:(___)_____________

Signature:______________________________________________________

 Employed:

Full Time

Part Time

Retired

Not

 Students:

School Name:_______________________________________

Address:____________________________________________________

 Full-time

Part-time

 

Insurance Information

Primary Insurance Company:

Name:__________________________________

Address:________________________________

_______________________________________

Does your plan cover:Dental MedicalBoth

Group Name:________________

Group #_________________Local:___________

 

Insured Party: Name:__________________________

Relation to insured:Self Spouse Child Other

Street:___________________________________________

City:_________________State:______Zip:_______________

Home:(___)________________Work:(___)_________________

Date of Birth:________________Soc.Sec.#______________________

 Primary Insurance: Employer Information:

Is this an Employer's Health Insurance Plan?

Yes No

Employer ID Number:____________________

Name:________________________________

 Address:

Street:_______________________________

City:_________________________________

State:____________Zip:_________________

 Secondary Insurance Company:

Name:__________________________________

Address:________________________________

_______________________________________

Does your plan cover:Dental MedicalBoth

Group Name:_________________

Group #_________________Local:___________

Insured Party:

Name:________________________________________

Relation to insured:Self Spouse Child Other

Street:__________________________________________

City:_________________State:______Zip:_______________

Home:(___)________________Work:(___)_________________

Date of Birth:________________Soc.Sec.#______________________

Secondary Insurance: Employer Information

Name:_______________________________

Is this an Employer's Health Insurance Plan?

Yes No

Employer ID Number:_____________________

Employer Address:

Street:_______________________________

City:_________________________________

State:____________Zip:_________________

Fees and Payments:

We make every effort to keep down the cost of your oral surgical care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms but please complete the identifying information at the top of the form.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and other pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. Any account over 90 days will be charged a 11/2% finance charge monthly with an annual rate of 18%. I agree that my account will be debited electronically for both face amount and returned check fees if returned unpaid.

This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorized payment directly to the dentist named, of the insurance benefits otherwise payable to me.

Signature:__________________________________________________________

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