PATIENT REGISTRATION

to :

First Name

Patient ls:

Chart lD

Lasl Namer Middle lnitialt-_] Poticy Hotder

[--l Responsible Party

Responsible Par$ (if someone other than the patient)

First Name Last Name Middle Initial.

Address:

City, State, Zip

Home Phone:

Birth Date

Pager

Work Phone:

Preferred Name

Exl

Soc. Sec Drivers Lic:

O Responsible Party is also a Policy Holder for Patient O Pnmary Insurance Policy Holder O Secondary Insurance Policy Holder

Patient Information

Address: Address 2:

C i t y : - _ S t a t e / Z i p . _ _ P a g e r

Work Phone: Ext: Cellular:Home Phone

Sex. )Ma le ( Female Marital status: (--r Manieo l) Singte Q Divorced (J Separated (J Widowed

Birth Date: _ _ Age: Soc. Sec:_ ._ Drivers Lic:

E-mail l_l I would like to receive corresoondences via e-mail

Employment Status: ( ) Futt lime f) eart fime () RetireO Additional Comments:

Student Status , I Full Time ( ) eart Time

Section 2 Section 3

Medicaid lD.

Employer lD

Name of Insured.

Insured Soc. Sec

Pref. Denlist:

Pref. Pharmacy:

Carrier lD: . Pref. Hyg :I

Prrmarv lnsurance lnformation

Relationship to Patient:() Sef f _) Spouse (,) CfrilO (' ) Other

lnsured Birth Date:

Employer lns Company.

Address: Address:

Address 2: Address 2:

City,State,Zip: City,State,Zip.

[*:'.00 Rem. Deduct:

I Secondary Insurance Informatron -I| ' Relationship to Patient:O ser () spouse C) child (_) otnerI Name of Insured:

Insured Birth Date

Ins Company: _

Address:i

Insured Soc. Sec

Employer

Address:

Address 2:

City,State,Zip:

Rem. Benefits:

Address 2:

City,State,Zip:

Rem. Deduct 00

Financial Terms and AgreementPlease read the following terms and sign at the bottom to indicate your acceptance of our office financial terms and policies.Thank you.

L Palment is due at the time services are rendered.2. We accept the following forms of payment: Cash, Personal Check, Visa, Mastercard, Discover,Nows. We also offer an extended payment plan

with prior crcdit approvalUCR (Usual and Customary Rates) Our practice is committed to providing the best treatment possible for our patients and we charge what is usualand customary for our area. You are responsible for paynrent in ful l regardless of any insurance company's arbitrarydetermination of usual andcustorrary rates. Insurance estimates nre just that, estimntes only, you are respotrsiblefor any amounts remaining after insurance pays.Minor Patrents The adult accompanyrng a minor and the parcnts (or guardians) are responsible for ful l payment. For unaccompanied mrnors, non-erlrcrgency treatmcnt wil l bc denicd unless chargcs have becn pre-authorizcd to an approved credit plan, Visa./Mastercard./Discover, or pa)rnent bycash or check at t i rne ofservice has been veri f icd.An appointment is a resen'at ion. When you make an appointment, that trme is not given to anyone else. Without adequate notice of your inabi l i tyto kecp your appointrnent, we are not able to give that t i rrc to anyone else jn need of dental care and that valuable t ime is lost. We do reserve theright to charge for missed appointments or cancel lat ions u i thout r i t least 2.1 hours notice. A message left on our answering service on Friday does notconsti tutc 24 hours notrce ofcancellat ion for a Monday appointment sjnce the off icc is closed on Friday.If 'you have dcntal bencfi ts, plcasc indrcate your prefened mcthod ol 'paymcnt for thc services you receive in our off ice:

_ _ l w i l l p a y l b r t h e s c r v i c c s l r e c e i v e o n t h c d a y o f n r y a p p o r n t m e n t a n d s u b m i t t h e c l a i m f o r f o r r e i m b u r s e m e n t m y s e l f . I w o u l d l i k e D r .loch 's s ta l l ' to p rov ide mc w i th a conrp lc tcd c la im fo rnr .

__ __l *,ould l ikc to assign benefi ts to f)r. Zoch. I understand that I rvi l l be expected to pay my estimated share (co-payment) on thc day servicesure prov idcd I a lso unders tand tha t ANY amount tha t i s no t covcrcd /pa id by nry insurance company is MY respons ib i l i t y . My s ignature w i l l bekcpt on f i le for al l clalms subnrit ted on rny behalf.

* l 'or patients choosing to assign beneli ts: By accepting assignnrent of-bencfi ts, thc doctor rs agrecing to delaycd pa).rnent for services providcd for up to 45days or unti l a check is rcceived f iom thc insurance company. Sincc thc patrcnt is ult imately rcsponsible for ALL fces incurred regardlcss ofthe lcvel ofrcrnrbursemcnt by thcir insulancc comprny, acccpting assignment is equrvalent to extcnding crcdit to the insured/guarantor ofthe account. Therefore, werequire a guarantee ofthe balance assigned in the form ofa credit card.

Signature on File for Assignment of BenefitsI authorize relcase of any inlbrmation rclat ing to the claims Dr. Frcd F Zoch wil l subrnit on my bchalf for the dental services rendered in his off ice. Iunclcrstand that I am rcsponsiblc lor al l costs ofdcntal treafnrent.

Srgned (Pa t r cn t o r Pa rcn t o f ' a n r i t t o r )

I hcrcby author ize pa).nrent of the dental benel l ts otherwise payable to rne di rcct ly to Fred F Zoch DDS.

Datc

S i rncd l lnsurcd Person)

Please circle vour choice ol credit card lor account guarantee: l \ lastercard

Datc

Visa Discover Dental Credit Card

\ r . rn re l i s i t ap t rcars on card (P lease Pr in t )

. . \ r ,o t r t t l NurnberI authorize Dr. Fred l- Zoch and his stalTto kecp ml,signature on f i le antl to charge my credit card for any claim not paid by my insurance compan)'rvi thin. l5 dals ofthe day t lre claim rvas sent or lbr any balance remaining on a claim al ler insurance payment has been received.

S ign i i t u rc o f c l rdho lder

FOR ALL PATIENTS: I understand and agree to the terms outl ined in this Financial Agreement.treatment,

Date

I agree to be responsible for al l costs of my dental

\enspaper Advert isement_ Magnet Letter_ Phone Book(Describe) Other

DateSrrlnature ofPatient. I fa minor, stgnature ofpatient 's parent or guardian,

\! 'hom may we thank lbr referr ing ) 'ou to our olf ice?

NOTICE OF PRIVACY PRACTICESFred Zoch DDS2525 Texas Ave.

409-735-71 08Fax 409-735-6596

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GETACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We respecl our legal obl igation to keep health information that identi f ies you private. We are obl igated by law to give you notice ofour privacy practices. This Notice describes how we protect your health rnformation and what r ights you have regarding i t .

TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONSThe most common reason why we use or disclose your health information is for treatment, payment or health care operations.

Examples of how we use or disclose information for treatment purposes are. sett ing up an appointment for you; examining your teeth.prescribing medications and faxing them to be f i l led; referr ing you to another doctor or cl inic for other health care or services; or gett ing copiesof your health Informatton from another professional that you may have seen before us. Examples of how we use or disclose your healthinformation for payment purposes are: asking you about your health or dental care plans, or other sources of payment; prepaiing andsending biJls or claims, and col lect ing unpaid amounls (ejther ourselves or through a col lect ion agency or attorney). "Health care operations"mean those administrat ive and managertal functions that we have to do in order to run our off ice. Examples of how we use or disclose yourhealth information for health care operations are: f inancial or bi l l ing audits, internal qual i ty assurance; personnel decisions; part icipation rnmanaged care plans; defense of legal matters; business planning; and outside storage of our records.

We routinely use your health information inside our off ice for these purposes without any special permission. l f we need to discloseyour health information outside of our off ice for these reasons, we usuallv wi l l not ask vou for soecial writ ten oermrssron.

USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSIONIn some l imited situations, the law al lows or requires us to use or disclose your health information without your permission. Not al l

of these situations wil l apply to us; some may never come up at our off ice at al l . Such uses or disclosures are.. when a state or federal law mandates that certain health information be reported for a specif ic purpose;o for publ ic health purposes, such as contagious disease report ing, investigation or survei l lance; and notices to and from the federal

Food and Drug Administrat ion regarding drugs or medical devices,. disclosures to governmental authorit ies about vict ims of suspected abuse, neglect or domestic violence;. uses and disclosures for health oversight act ivi t ies, such as for the l icensing of doctors; for audits by Medicare or Medrcaid; or for

investigation of possible violat ions of health care laws;. disclosures for judicral and administrat ive proceedings, such as in response to subpoenas or orders of courts or administrat ive

agenc ies ,. disclosures for law enforcement purposes, such as to provrde information about someone who is or is suspected to be a vict im of a

crime, to provide information about a crime al our off ice; or to report a crime that happened somewhere else;. disclosure to a medical examiner to identi fy a dead person or to determine the cause of death; or to funeral directors to aid in burial,

o r to o rgan iza t tons tha t hand le o rgan or l i ssue donat ions ,. uses or disclosures for health related research;. uses and drsclosures to prevent a serious threat to health or safety,. uses or drsclosures for specialtzed government functions, such as for the protection of the president or high ranking government

off icials, for lawful national intel l igence activi t ies, for mil i tary purposes; or for the evaluation and health of members of the foreiqnservice,

o disclosures of de-identi f ied information;. disclosures relatrng to worker's compensation programs;. disclosures of a " l imited data set" for research, publ ic health, or health care operations;o incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;o disclosures to "bustness associates" who perform health care operations for us and who commit to respect the privacy of your

health information;. IEDIT: [specify other uses and disclosures affected by state law] l

Unless you object, we wil l also share relevant information about your care with yourfamily orfr iends who are helping you with yourdental care.

APPOINTMENT REMINDERSWe may cal l or write to remind you of scheduled appointments, or that i t is t ime to make a routine appointment. We may also cal l

or write to noti fy you of other treatments or servtces avai lable at our off ice that might help you. Unless you tel l us otheruise, we wil l mail youan appointment reminder on a post card, and/or leave you a reminder message on your home answering machine or with someone whoanswers your phone i f you are no t home.

OTHER USES AND DISCLOSURESWe wil l not make any other uses or disclosures of your health information unless you sign a writ ten "authorization form." The

conten to fan"author iza t ion form" isdeterminedbyfedera i law. Somet imes,wemay in i t ia te theauthor iza t ionprocess i f theuseord isc rosureis our rdea. Sometimes, you may initrate the process i f i t 's your idea for us to send your information to someone else. Typical ly, in thissituation you wil l give us a properly completed authorization form, or you can use one of ours.l f we inLtiate the process and ask you to sign an authorization form, you do not have to sign i t . l f you do not sign the authorization, we cannotmake the use or disclosure l f you do sign one, you may revoke i t at any t ime unless we have already acted in rel iance upon i t . Revocations

must be In writ ing Send them to the office contact person named at the beginning of this Notice,

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION' The law gives yotr many r ights regarding your heal th lnformat ion. You can:

' ask-us to restrlct our uses and disclosures for purposes of treatment (except emergency treatment), payment or health careope ra t i ons . Wedono t have toag ree todo th i s ,bu t i fweag ree ,wemus thono r the res t r i c t i ons tha tyouwan t , Toask fo rarestrlction"send a written request to the offic€ contact person at the addresg, fax or E- Mail:sho.wn at the beglnnlng of this Notlco.

r ?sk us to cornmunicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing healthinformation lo a different address, or by using E mail to your personal E Mail address. We will accommodate these requests i l theyare reasonable, and if you pay us for any extra cost. lf you want lo ask for confidential communications, send a written request tothe office contact person at the address, fax or E mail shown at the beginning of this Notice.

r ask to seo or to get photocoples of your health information. By law, there are a few limlted sitqations in which we can refuse topermlt access or copying. For the most.part, however, you wil l be able to review or have a copy of your health information within30dayso !ask ingus (o r - s i x t ydays i f t he in fo rma t i on l ss to redo f f - s i t e ) . Youmayhave topay fo rpho tocop les lnadvance . l fw€deny yourrequest, wo wil l send you a written explanatlon, and instructions about how to get an impartlal revlew of our denlal if oneis legally available, By law, w€ can have one 30 day exlension of the l ime for us to giva you access or photocopies lf we send youawr i t t enno t i ceo f theex tens ion . l f youwan t to rev ieworge t pho tocop ies 'o f you rhea l t h l n fo rma t i on , sendawr i t t en reques t to t heofflce contact person at the address, fax or E mail shown at lho beginning of this Notice.

r 8sk us to amend your health Information if you think that it is incorrect or Incomplete. lf we agree, we wll l,a;hend the Informationwithin 60 days from when you ask us, We will send the corrected information to'persoris who we know gtStlthe wrong Information,and others thal you specify. lf we do not agr€o, yau can writo a statement of your positlon, and We will include it with your healthinformation along with any rebuttal statement lhat we may write. Once your statement of position and/or our rebuttal is lncluded inyou rhea l t h i n fo rma t i on ,wew i l l send i t a l ongwheneve rwemakeaperm i t t edd i sc losu reo fyou rhea l t h i n fo rma t i on , By law ,wecanhave ons 30 day extension of t ime to conslder a request for amendment lf wo notify you ln writ ing of lhe extension, lf you want loask us to amend your health inforrhation, tend a written request, including your rdasohs for the amendment, to the offics contactperson at the address, fax or E mail shown at the beg)nning of this Notice.

r Set a l lst of the disclosurss that we have made of your health Informaiion withln the pastislx years (or a shorter.perlod lf you want).By law,' the l ist wil l not Include: disclosures for purpopes of treatment, payment or health caro opefations; disclosures with youraulhorization; Incidental disclostrres; disclosures reqrlired by law; and some other l lmited discloiures. You are enfit led{o one sucnlist per year without charge. lf you want more frequent l ists, you wil l have to pay for them in advarlce. We will usually respond toyour request within 60 days of receiving it, but by law we can havo ono 30 day extension of t imp if we notify.you of thg exlension Inwrit ing.,lf you want a l ist, send a written /equest lo the offlcs contact person at tho address, fax or E mail shown at tho beginning ofthis Notice.

o Qet a(ditional paper copies of this Notice of Prlvacy Practrces upon request. [t does not matter whether you got one electronicallyor In paper form alroady. lf you want additional paper copies, send a written request to the office contact person at the address, faxor E mal t shown at the beginning of th is Not ice.

OUR NOTICE OF PRIVACY PRACTICESBy law, we must abide by the terms of this Notice of Privacy Practices until We choose to change it. We

reserve the right to change this notice at any time as allowed by law. lf we change this Notice, the new privacypractices will apply to your health information that we already have as well as to such information that we maygenera te in the fu tu re . l fwechangeourNo t i ceo fP r i vacyPrac t i ces ,wew i l l pos t thenewr io t i ^e inou ro f f i ce ,havecopies available in our off ice, and post i t on our Web site.

COMPLAINTSlf you think that we have not properly respected the privacy of your health information, you are free to

complain to us or the U,S. Department of Health and Human Services, Off ice for Civi lrRights. We wil l not retal iateagainst you if you make a complaint. l f you want to complain to us, send a written complaint to the off ice contactpe rsona t theaddress , faxo rEma i f showna t thebeg inn ingo f th i sNo t i ce , l f youp re fe r , youcand iscussyourcomplaint ln person or by phone,

FOR MORE INFORMATIONlf you want more information about our privacy practices, call or visit the office at'the address or phone

number shown at the beginning of this Notice.

I acknowledge that I

Pa t ien t name

ACKNOWLEDGEMENT OF RECEIPT

received a copy of Dr, Fred Zoch's Notice of Privacy Practices,

Signature Date