New Patient Forms

Patient Information

Responsible Party

Insurance Information

Assignment of Benefits and Terms of Payment

I authorize the release of any medical treatment necessary to process a claim on any insurance policy. I hereby assign to and authorize payments to Joby L. Hurst, D.M.D., M.S., P.C., of all benefits payable under such insurance policy. “This information is given for the purpose of establishing an account and medical file with Joby L. Hurst, D.M.D., M.S., P.C. It is understood that I will be responsible for all present and future services. I DO UNDERSTAND THAT REGARDLESS OF THE INSURANCE COVERAGE THAT I HAVE, I AM RESPONSIBLE FOR PAYING ALL CHARGES. In the event of non-payment of charges for dental services rendered, I agree to pay all costs of collection, including a reasonable attorney’s fee, and I further waive all rights of exemption as to personal property under the constitution and laws of the State of Alabama. I have read this agreement and do understand its provisions.” *PLEASE BE AWARE THAT WHOEVER ACCOMPANIES THE PATIENT AND SIGNS ALL NECESSARY FORMS IS RESPONSIBLE FOR PAYMENT OF ALL PROCEDURES, REGARDLESS OF WHOSE INSURANCE THAT PATIENT IS COVERED UNDER. I understand and authorize all dishonored checks plus a processing fee if applicable to be electronically debited from my account.

Secondary Insurance?

Second Insurance Information

Health Insurance

Hospital or Injury ONLY

Medical History

Has your child been diagnosed with diseases or conditions relating to any of the following:

Dental History

Patient Authorization

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); Obtaining 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, a 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. 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 this 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.