Drs. Rubens & Steen

18807 Beardslee Blvd., Suite 102
Bothell, WA 98011

Phone: (425) 489-8274
FAX: (425) 487-9506
PATIENT REGISTRATION
First Name   MI   Last Name   Title
Address   City   State   Zip
Home Phone   Work Phone   Cell
Email
Mailing address if different than above:
Address   City   State   Zip
Date of Birth    Age       Sex Male Female      Soc. Sec. #
What is your occupation?
Are you a student? Yes    No    School:
Have you or a member of your family been a patient of Dr. Steen/Peysakhov before? Yes    No
Whom/When?
Who referred you?  
Who is your general dentist?
Emergency Contact: Name   Phone
How may we help you? [reason for your referral to our office]:
Who Is Financially Responsible For Your Account?
Name   Relationship
Address   City   State   Zip
Phone    Cell
Email
Primary Insurance Company:        Dental    Medical    Both
Name   Phone
Address   Group No.
Primary Subscriber:       Social Security No.
Name   Phone
Address   City   State   Zip
Birth Date    Sex Male Female       Cell
Employer   Phone
Patient Relationship To Insured: Self Spouse Child    Other
Secondary Insurance Company:        Dental    Medical    Both
Name   Phone
Address   Group No.
Seconday Subscriber:       Social Security No.
Name   Phone
Address   City   State   Zip
Birth Date    Sex Male Female       Cell
Employer   Phone
Patient Relationship To Insured: Self Spouse Child    Other
 
As A Courtesy To Our Patients:
The office staff will communicate with your insurance company(s) to help verify insurance coverage limits, help you to obtain your maximum benefits, and help provide an estimate based on your insurance plan. Due to the many types of insurance plans and companies that we interact with in both the medical and dental insurance realms, our estimates of your coverage may be affected by:
  • Your individual insurance plan’s “maximum benefits”
  • Pre-authorization requirements
  • Eligibility at the time of servic
  • Any specific plan limitation
  • Any pending claims being processed
  • Individual insurance company interpretation of the UCR [usual and customary fees]
  • Our participation in dental plans that may influence our fees

In spite of our best attempts to accurately predict your individual coverage, there may be a balance due after your service has been provided. When your insurance is entirely processed, we will notify you of any balance owed [or balance due back to you] to make appropriate payment arrangements. If you have specific concerns about your insurance coverage, we recommend you personally contact your insurance company for clarification of coverage benefits since the insurance contract you have is between your insurance company and you. When in doubt, you also may obtain a written pre-authorization from your insurance company.

Assignment Of Benefits And Records Release Authorization:
I hereby authorize my insurance benefits to be paid directly to Dr. Steen/Peysakhov. I am financially responsible for any balances due. I also authorize Dr. Steen/Peysakhov to release any information required for this claim

In consideration of the service rendered to me by this dental office, I am obligated to pay said office in accordance with its credit terms and policy. In the event a collection action should be required, I agree to pay the costs of collection including, but not limited to, the collection fees, court costs and reasonable attorney fees.

 
 Signature Date
This form  will be retained in the patient’s record close