Patient Registration 1Patient Information2Phone Numbers3Financial Responsibility / Dental Insurance4Privacy Practices and Cancellation Policy Patient Name* First Last Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Sex M F DOB Month Day Year Marital Status Single Married Widowed Divorced Patient/Guardian SSN Occupation Employer Spouse's Name Spouse's DOB Month Day Year Spouse's SS# Spouse's Employer Whom may we thank for referring you? Cell Cell Carrier Home Work Email Reminder via: Home Cell Work Text Email Emergency Contact Relationship to You Home Cell Subscriber Name First Last DOB Month Day Year Relationship to patient Ins ID# or SS# Insurance Co. Group# Insurance PhoneEmployer Is patient covered by other insurance? No Yes Subscriber Name First Last DOB Month Day Year Relationship to patient Ins ID# or SS# Insurance Co. Group# Insurance PhoneEmployer Assignment and Release I certify that I (or my dependent) have insurance coverage and assign directly to Patrick J. McCoy, DDS all insurance benefits, if any, for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.Responsible Party SignatureRelationship to Patient Date MM slash DD slash YYYY I acknowledge that I have been offered a copy of the Statement of Privacy Practices for the office of Patrick J. McCoy, DDS. The Statement of Privacy Practices describes uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office healthcare operations. The posted Statement of Privacy Practices describes my rights and the responsibilities of this office with respect to my protected health information. Patrick J. McCoy, DDS reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If changes occur I will be offered a revised copy at the first visit after the revision is made. Additional Disclosure In addition to the allowable disclosures described I authorize disclosure of my protected health information to the persons indicated below. Any member of my immediate family Spouse only Patient Name Is Patient a Minor?* No Yes Patient SignatureGuardian SignatureThis office has a 48 business hour cancellation policy. If you miss or late cancel your scheduled dental appointment you will be charged a $50 fee per appointment.SignatureRelationship Date MM slash DD slash YYYY