Cal Dental Group Pasadena

1213 N. Lake Ave, Suite 1 Pasadena, CA 91104

626-584-1800

PATIENT REGISTRATION

Name:
Nickname:
Address
City:
State:
Zip:
Phone
Soc Sec. #
DOB
Present Age
Sex
Marital Status
Occupation
Employer
Since
Employer's Address
Spouse
Soc. Sec. #
DOB
Occupation
Employer
Since
Employer's Address
E-mail address
Person Responsible For Account (If different from above)
Name
Relationship
Address
Soc. Sec. #
Occupation
Employer
Since
Insurance
Primary
Secondary
In Case of Emergency Contact
Name of nearest relative
Relationship
Address
Phone
Who Referred You To Our Office
Name
Relationship
Address
Authorization, Terms & Conditions

I grant authority to the Dentist to perform procedures and treatment, including administration of medicine, local and general anesthetics, and extractions along with other surgical and dental procedures that may be necessary. I have received (or have been offered) a copy of this office’s Notice of Privacy Practices and “The Dental Materials Fact Sheet”. By signing this form, you are giving this office your consent to use and disclose health information about you for treatment, payment, and health care operation purposes.

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. If your insurance carrier does not remit payment within 60 days, the balance will be due and payable by you. Please have your completed insurance claim form with you at the first visit.

AUTHORIZED SIGNATURE

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Date
Witness Initials

Assignment of Benefits Form

I hereby assign all dental benefits, to which I am entitled, to Dr. Sean Sunyoto. I authorize and direct my insurance carrier(s) to issue payment checks directly to Dr. Sean Sunyoto for dental services rendered to myself and or my dependents. I understand that I am financially responsible for all charges not covered by insurance.

Authorization for Release of Information:
I authorize Dr. Sean Sunyoto to:

  1. Release any necessary information to my insurance carriers regarding my treatment.
  2. Process insurance claims generated during my examination or treatment.
  3. Use my signature on all insurance submissions for a lifetime, unless I revoke this authorization in writing.
  4. I understand that by requesting dental services from Dr. Sean Sunyoto, I am responsible for all charges incurred, whether or not they are covered by insurance. I agree to pay any outstanding balance upon presentation of a statement.

A photocopy of this form shall be considered as valid as the original.

Notice of Privacy Practices Acknowledgment (HIPAA):
I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have rights to privacy regarding my protected health information. I acknowledge that I have been informed of Dr. Sean Sunyoto's Notice of Privacy Practices, which outlines how my health information may be used and disclosed.

I understand that:

This information may be used to conduct and manage my treatment, obtain payment from third-party payers, and carry out normal healthcare operations. I can request a copy of the Notice of Privacy Practices at any time. I may request restrictions on how my health information is used or disclosed, but Dr. Sean Sunyoto is not required to agree to these restrictions unless they are legally obligated to do so.

Patient or Responsible Party Signature

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Date

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