Daniel Mueth DDS PC - Patient Information (Dr. Mueth form)

Patient Information
Date

Month Day Year
Date
Name *

First Name Middle Name Last Name
Sex
The patient is

Child Student
Marital Status
Partnered for how many years
If child, provide parent/guardian name(s) below
If student, please complete
Student Status
School/Location
Patient Date of Birth

Month Day Year
Date
Social Security Number/HIC/Patient ID Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Referral?

Yes No
Referred by
Emergency Information
In case of emergency, who should be notified?

First Name Last Name
Relationship
Phone Number
Please enter a valid phone number.
Employment Information
Employer
Occupation
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Work Phone
Please enter a valid phone number.
Direct Phone
Please enter a valid phone number.
Employer Email Address
example@example.com
11166 Tesson Ferry Rd. Suite 210
Saint Louis, MO 63123
Tel: 314-729-0489
WWW.DANIELMUETHDDS.COM

INSURANCE INFORMATION
Subscriber's Name

First Name Middle Name Last Name
Preferred Name
Title
Subscriber Date of Birth

Month Day Year
Date
Subscriber Social Security Number
Subscriber Employer
Patient Relationship to Subscriber

Self Spouse Child Other
PRIMARY INSURANCE CARRIER
Primary Insurance
Group/Policy Number
ID Number
Insurance Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Telephone Number
Please enter a valid phone number.
Toll Free
Do you have additional insurance?

Yes No
SECONDARY INSURANCE CARRIER
Secondary Insurance
Group/Policy Number
ID Number
Insurance Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Telephone Number
Please enter a valid phone number.
Toll Free
Fax Number
Please enter a valid phone number.
11166 Tesson Ferry Rd. Suite 210
Saint Louis, MO 63123
Tel: 314-729-0489
WWW.DANIELMUETHDDS.COM

AUTHORIZATION
I certify that I, and/or my dependents(s), have insurance coverage with {primaryInsurance518}, {secondaryInsurance526} and assign to Dr. Daniel Mueth D.D.S. P.C. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for the charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
Signature of Patient, Parent, Guardian, or Personal Representative *

Clear
Date

Month Day Year
Date
Name of Patient, Parent, Guardian, or Personal Representative

First Name Last Name
Relationship to Patient
11166 Tesson Ferry Rd. Suite 210
Saint Louis, MO 63123
Tel: 314-729-0489
WWW.DANIELMUETHDDS.COM

PATIENT CONSENT FORM
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:
- Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)
- Obtain payment from third-party payers (e.g. my insurance company
- The day-to-day healthcare operations of your practice
I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with the restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.

Signed this day {date}
Patient Name

First Name Last Name
Relationship to Patient
Signature *

Clear
Practice Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
11166 Tesson Ferry Rd. Suite 210
Saint Louis, MO 63123
Tel: 314-729-0489
WWW.DANIELMUETHDDS.COM

FINANCIAL POLICY
Thank you for choosing Dr. Mueth for your dental care. We are committed to providing the best quality care to each of our patients. Please understand that payment of your bill is considered a part of your responsibility in this relationship. The following is a statement of our Financial Policy to help you understand your obligation, which we require you to read and sign.

Regarding Insurance/Co-Pays
All charges will be submitted to your insurance plan for which coverage is in effect. Actual benefit payments are determined only after a claim is received by your insurance company. Eligibility is not a guarantee of coverage. Co-pays on treatment are an estimate of what your insurance may pay. Any and all remaining balance is your responsibility and payable 30 days from your statement date.

Trauma and Accident Related Injuries
This office does not accept assignment of benefits for charges related to accident or trauma. The patient/guardian is responsible for all charges at the time of service.

Minor Patients
The adult accompanying a minor patient (patient, legal guardian, grandparent, etc.) will be responsible for payment of the co-pay or any pre-determined charges not covered by insurance AT THE TIME OF SERVICE.

Adolescent Patients
Adolescent patients not accompanied by a parent are responsible for payment of the co-pay or any pre-determined charges not covered by insurance AT THE TIME OF SERVICE.

SEPARATION/DIVORCE POLICY
Dr. Daniel Mueth, DDS, PC is not party to any separation or child support agreement or divorce decree. The parent accompanying the child is responsible for paying the co-pay or any charges pre-determined not covered by insurance AT THE TIME OF SERVICE.

Balances for services denied by insurance are due to full thirty days after the date of the first monthly statement regardless of the terms of separation or child support agreement or divorce decree. It is your responsibility to keep our office informed of any address, phone number, or insurance changes as we can only work with the information provided to us.

Dental Insurance Downgrade Policy
Many insurance companies downgrade the cost of posterior restorations; including crowns, fillings, and bridges. Our office uses tooth-colored materials on all restorations. Patients are responsible for the alternative benefit balance not paid by your insurance.

Any account balance remaining unpaid after an initial 30 days will be charged a $10.00 late fee and an interest rate of 1.5% of the account balance monthly until paid in full. In the event you are unable to keep your appointment, we do request that you kindly give us a 24-hour notice to avoid a $25.00 missed/cancelled appointment fee. A $25.00 fee will be applied for all returned checks.

I understand that I am responsible for the charges incurred. In the event that I fail to pay these charges, I will be responsible for an additional 29% of collection cost and/or attorney fees associated with the cost of resolving my account.

I, {name}, have read the Financial Policy and I understand and agree to these Patient Name/Responsible Party terms.
Signature of Responsible Party *

Clear
Date

Month Day Year
Date
11166 Tesson Ferry Rd. Suite 210
Saint Louis, MO 63123
Tel: 314-729-0489
WWW.DANIELMUETHDDS.COM

NO SHOW POLICY
Dear Patient:

Scheduled dental appointments are very important. They allow the patient and the doctor to have a productive time. They are a prerequisite for excellent quality care.

To better serve you, please call 24 hours in advance if you are unable to keep your appointment so we can allocate the time slot for other patients. If you don’t show up for your appointment without prior notice, there will be a $25.00 fee assessed to your account.

Thank you for your cooperation.

I have read and understand the NO SHOW POLICY as written above.
Signature *

Clear
Date

Month Day Year
Date
Please verify that you are human *
11166 Tesson Ferry Rd. Suite 210
Saint Louis, MO 63123
Tel: 314-729-0489
WWW.DANIELMUETHDDS.COM
Should be Empty:

Patient Information

If student, please complete

Emergency Information

Employment Information

INSURANCE INFORMATION

PRIMARY INSURANCE CARRIER

SECONDARY INSURANCE CARRIER

DENTAL HISTORY

Previous Dentist Information

MEDICAL HISTORY

FEMALE PATIENTS

MEDICATION INFORMATION

AUTHORIZATION

PATIENT CONSENT FORM

FINANCIAL POLICY

NO SHOW POLICY