Adult Medical Form

If you wish to file dental insurance or Medicaid/Medicare, please tell the receptionist so we can obtain the information necessary to file for you. Please provide the front desk with your insurance card and photo ID.

The undersigned understands that insurance or Medicaid coverage does not relieve him/her of the responsibility of payment of the entire account if third party payment is not received. Estimates given by our staff are not a guarantee of the insurance or Medicaid payments as these third parties will not guarantee payments until a claim is received. Estimates are based on information we have at the time regarding your coverage. The undersigned is responsible for the payment of services rendered in addition to the head of household. If the patient is a minor BOTH parents are responsible. If the undersigned is not the patient it is understood that the patient is also responsible for payment of services provided for him/her.

In event of nonpayment resulting in default of the account should Morrison Dental Associates, PC refer this account to an attorney, I agree to pay and indemnify Morrison Dental Associates, PC against legal cost and charges including, but not limited to, reasonable attorney's fees, court cost and disbursements. I further grant permission to release information contained on this information sheet to any attorney in order to collect the amount due. Interest shall accrue on the account at the rate of 1.5% per month, 18% annum, on the unpaid balance. Payment in-full is due at the time of service. Any account not paid at the time of service is due in-full within thirty (30) days of services. If account is not paid at the time of service, Morrison Dental Associates, PC is authorized to obtain a report from a credit reporting agency regarding my credit history.

*** Member Equifax Credit Reporting Services ***
As required by law, you, herby notified that a negative credit report reflecting on your credit records may be submitted to a credit reporting agency if you fail to fulfill the terms of your credit obligations.

I the undersigned, do hereby authorize Morrison Dental Associates, PC to exam and treat the patient as deemed necessary by the dentist. If the undersigned is not the patient, he/ she assumes all responsibility for the accurateness of the medical and dental information furnished on this form. I further affirm that the medical and dental information is correct, and the patient does not have any communicable disease which would be infectious to those providing services for him/her or others coming in contact with the patient in the office. This authorization is good for two years.

This is to advise you that Morrison Dental Associates, P.C. is privately owned and operated. As providers of care and owners of this corporation, we reserve the right to discontinue services to patients who:

• Are unwilling to follow medical recommendations or treatment plans.
• Are unwilling to schedule recommended follow-up visits or tests as prescribed by our providers or repeatedly miss scheduled appointments.
• Use vulgar, demanding or abusive speech towards our staff, providers, or other visitors to our facility.
• Demonstrate abuse of medication, equipment or supplies.
• Damage our property or grounds.
• Display threatening behavior (by phone or in person) of any kind toward staff, providers or other visitors to our practice.
• Enter the clinical areas unescorted or otherwise violates patients' privacy act as outlined under HIPPA.
• Are disrespectful of the needs of other patients visiting our practice.

In Addition to the above, should any visitor accompanying a patient display any of the above behaviors, we reserve the right to discontinue service to the patient. We feel the above actions are necessary to ensure a friendly, safe and secure environment as well to ensure respectful and efficient business operations.

If you wish to file dental insurance or Medicaid please tell the receptionist so we can obtain the information necessary to file for you.

The undersigned understands that insurance or Medicaid coverage does not relieve him/her of the responsibility of payment of the entire account if third party payment is not received. Estimates given by our staff are not a guarantee of the insurance or Medicaid payments as these third parties will not guarantee payments until a claim is received. Estimates are based on information we have at the time regarding your coverage.

We will bill participating insurance companies as a courtesy to you. Therefore, we will request a copy of your insurance card at each visit. Please understand that insurance is a contract between you and your carrier. Therefore, you are ultimately responsible for your bill. You are responsible for knowing the coverage, limitations, waiting periods, and exclusions specific to your insurance policy.

The undersigned is responsible for the payment of services rendered in addition to the head of household. If the patient is a minor BOTH parents are responsible. If the undersigned is not the patient it is understood that the patient is also responsible for payment of services provided for him/her.

In event of nonpayment resulting in default of the account should Morrison Dental Associates, PC refer this account to an attorney, I agree to pay and indemnify Morrison Dental Associates, PC against legal cost and charges including, but not limited to, reasonable attorney's fees, court cost and disbursements. I further grant permission to release information contained on this information sheet to any attorney in order to collect the amount due. Interest shall accrue on the account at the rate of 1.5% per month, 18% annum, on the unpaid balance. Payment in-full is due at the time of service. Any account not paid at the time of service is due in-full within thirty (30) days of services. If account is not paid at the time of service, Morrison Dental Associates, PC is authorized to obtain a report from a credit reporting agency regarding my credit history.