Patient Registration-New Patient Forms

Scott A. Reef, DDS, MSD and Justin J. Villanueva, DMD, MSD, DHL — Periodontal Associates of Lafayette IN

Insurance/Guarantor and Medical History Information Forms

• Patient Registration
• New Patient Medical History

We have an “Opt-out” status with Medicare. We cannot file claims with Medicare, nor can our patients for treatment. Dental procedures are not normally cover under traditional Medicare.

Notice of Privacy Policy

• Notice of Privacy Policy
• HIPPA Acknowledgement of PP

Please review the privacy policy, acknowledgment form, and release as you will be asked to sign these forms digitally upon your first visit to our office.

Release of Health Records

• Authorization for use and disclosure of patient information

Print, fill out, and mail, e-mail, or bring to the office for release of records to another specified entity.