Tin Wai Hui, DMD PA & Associates 16209 NE 13TH Avenue 600 S. Dixie HWY #105A 17901 NW 5th St. #206 12651 S. Dixie HWY #400 No. Miami Beach, FL 33162 W. Palm Beach, FL 33401 Pembroke Pines, FL 33029 Pinecrest, FL 33156 305.940.9888 561.820.8898 954.430.2188 305.595.4548 □North Miami Beach □West Palm Beach □Pembroke Pines □Pinecrest

*PATIENT’SNAME: (First) (MI) (Last)

Street Address Apt City State Zip

Home# Cell# Work#

Social Security # Driver’s License# *required*

Occupation Employer

Date of Birth / / Age Height Weight: Gender: Male / Female (Month/Day/Year) (Please circle)

*Emergency Contact: Relationship: *Phone:

If you are completing this form for another person, what is your relationship to that person? Your Name: Relationship:

Primary reason for this dental appointment: Examination Emergency Consultation Other

*RESPONSIBLE PARTY (if other than the patient)

Name Relationship (First) (MI) (Last) Street Address City State Zip

Telephone: Home Cell Work

*INSURANCE INFORMATION

INSURANCE SUBCRIBER RELATIONSHIP TO SUBSCRIBER SELF SPOUSE CHILD Other

Last Name First Name MI Last Name First Name MI Street City State Zip Code Street City State Zip Code

Home # Work # Email Home # Work # Email

Birth Date (Mo/Day/Year) Relationship to Patient Birth Date (Mo/Day/Year) Relationship to Patient

Employer Dental Insurance Company Employer Dental Insurance Company

Social Security # Subscriber/Member ID # Group # Social Security # Subscriber/Member ID # Group #

We are happy to file insurance claims and assist you in obtaining the maximum benefits specified in your contract.

1. We will do our best to ESTIMATE your coverage, and file your insurance on your behalf. Please be aware that your dental benefit program is a contract between you, possibly your employer, and the Insurance Company. We are not a party to that contract. We file insurance claims as a courtesy to you, our valued patient. You are responsible (not your insurance company) for all fees for services rendered. We will gladly assist you in any way we can.

2. Our office policy states that you are responsible for your bill. The ESTIMATED patient portion of the fee is due at the time of service. If a balance remains after we receive payment from your insurance carrier within 30 days we will notify you. Failure of your insurance carrier to reimburse our office within 30 days will result in our billing you directly for the remaining balance and will be subject to a 1.5% monthly interest or 18% APR, late fee together with expenses incidental to collection, including reasonable attorney’s fees and cost.

3. We are committed to providing the highest quality of care. Our treatment recommendations and the dental services we provide are in the best interest of the patient's health. The patient is responsible for payment in full regardless of an insurance company's arbitrary determination of treatment necessity.

4. If your coverage changes for any reason, please notify the office immediately. By signing this form, you have read and understand our policy. Any denials or insurance payments less than estimated will be your responsibility. Payment will be due upon our billing cycle. All estimated out of pocket fees and deductibles are due the day of treatment. Ask our office regarding our In House Dental Insurance and financial options before your visit, or if you have any questions regarding your insurance and our policy.

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* APPOINTMENT POLICY 1. You will receive a reminder 1-3 days prior to your appointment. Patients are kindly asked to confirm at least 24 hours prior to the scheduled appointment. Appointments can be confirmed by responding within the electronic notification, calling the office, or on the website contact page. Please Initial Here: ______

2. We require forty-eight (48) hours advance notice of cancellation. Patients who do not provide forty-eight (48) hours notice of cancellation or do not present for a scheduled appointment may be charged a fee. This fee will vary depending on the amount of time scheduled and will not be less than $30.00. Patients who fail to present for two (2) appointments risk being dismissed from the practice. Please Initial Here: ______