New Patient Form

Patient Name

Responsible Party Information: (for patients under the age of 18)

INSURANCE INFORMATION:

Our office is IN NETWORK FOR CIGNA, METLIFE, AMERITAS, AND DELTA. WE ARE OUT OF NETWORK FOR ALL OTHER INSURANCE COMPANIES.

We will need a copy of your current insurance cards, to assist in filling your claim.

Primary Dental Information

Medical Insurance Information

Check any of the following which you have had or have at present:

23. WOMEN/FEMALE:

To the best of my knowledge, all of the preceding answers are true, complete and correct. If ever have any change in my health or medications, I will inform the doctor at the next appointment. I request and consent to examination, records and photographs advisable in the doctor's opinion, which will be used only for patient care, education, research, or consultation with other health care professionals, I understand that informed consent will be given prior to any surgical procedure.

MARK M. PETRYNA, DDS, PA is authorized to release protected health information about the above named patient in the following manner and to identified persons.

Entity to Receive Information.

Check each person/entity that you approve to receive information.

Description of information to be released. Check each that can be given to person/entity on the left in the same section.

Patient Rights:

• I have the right to revoke this authorization at any time.
• I may inspect or copy the protected health information to be disclosed as described in this document.
• Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
• Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.
• I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.

The information is released at the patient’s request and this authorization will remain in effect until revoked by the patient.

I acknowledged upon request that I can receive a copy of the Privacy Practices for the above named practice.