NEW PATIENT FORM

WARNING! NEVER FAKE YOUR SIGNATURE!

If charged as a misdemeanor, the defendant can be sentenced to up to a year in jail, restitution to the victim and substantial court fines. If charged as a felony, the defendant can potentially be sentenced to up to three years in prison, in addition to fines and restitution.

Step 1 of 6

If you are a new patient, uploading your Driver’s License/Government Issued Photo ID and your Insurance Card will ensure the check-in process for your first appointment will be as quick as possible.



If you forgot to bring your dental insurance card. Ask our receptionist for assistance.



Carry Your Insurance Card



1. Your insurance card is essential. When you check in with the dental office reception, you will likely be asked for your dental insurance card. If you forget to carry your dental insurance card:

You can access your dental insurance card and coverage information by calling or electronically by logging in online. And get a copy/screenshot of your insurance card.

2. Inform the dentist receptionist immediately as soon as you check in. They will allow you to email your insurance card copy to yourdentistforms@gmail.com for your dentist to bill your dental insurance.

Why do you need a dental insurance ID card when you visit your dentist?



It is recommended. Your ID card tells your dentist the plan you're enrolled in to ensure you're charged the correct co-payment.

They were significantly needed if your employer changed your dental insurance plan since your last visit.

In case your dental insurance denies your dental claim. You or your dentist can appeal to the California Department of Insurance and One of the supporting documents.

HEALTHCARE PROVIDER REQUEST FOR ASSISTANCE (HPRFA) http://www.insurance.ca.gov/01-consumers/101-help/upload/RFAhealth.pdf

Needed are copies of your Dental Insurance card.

That is why you must always have proof of dental insurance in your possession.

INSTRUCTIONS

1. With your smartphone, take a picture of the front and back of your Photo ID and Insurance Card prior to starting this form.

2. To upload your images, click the “Choose a file” button and locate "Photo library" on the image on your phone.

3. Do not use the “Take Photo or Video” feature within the form.

4. To ensure your images upload properly, take the photos BEFORE you start the form. Do not use the “Take Photo” feature within the form. Except in SELFIE UPLOAD BUTTON

Contact our office at 510-792-4525 (Newark)

if you have any questions. Or ask the Receptionist to help fill up these forms while waiting for your appointment

NOTE: Your files are fully encrypted with HIPAA-compliant software to ensure security and privacy.

PLEASE SELECT FROM THE DROPDOWN MENU
PLEASE SELECT FROM THE DROP DOWN MENU
PLEASE SELECT FROM THE DROP DOWN MENU

Did you like this? Share it!

CALL NOW!