Patient Paperwork - Higginbotham Family Dental

Patient Paperwork must be completed at least 24 Hours prior to your appointment for proper processing.

Patient Information

Name *

First

Middle

Last

Preferred Name

Family Status *

Enter Other Status

Gender *

Ethnicity *

Race *

Language *

Date Of Birth Ex: 01012021 *

Social Security Number *

Driver's License #

Cell Phone *

Home Phone

Work Phone

Email *

Address *

Address Line 1

City

State

Zip Code

Office Location *

Referral Information

Medical History

Do You Have Any Medical Conditions or History? *

Currently Taking Any Medications? *

Have you ever been diagnosed with or taken medications for Osteoporosis? If yes, list medications. *

Are You Pregnant? *

Do you smoke? *

Do you drink alcohol? *

Do you take recreational drugs? *

To the best of my knowledge, all of the preceding answers and information provided is true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment time. (Type Your Name) *

Date *

Insured or Responsible Party Information

The Following Is For: (You Do Not Have To Fill Out This Section If You Select Self) *

Responsible Party Name

First

Last

Date Of Birth Ex: 01012021

Social Security Number

Cell Phone

Home Phone

Work Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Insurance Information

Do you have dental insurance?

Insurance Company Name

Insured's Name

First

Last

Insured's Date of Birth Ex: 01012021

Insurance Company's Address

Address Line 1

Address Line 2

City

State

Zip Code

Member ID # or Social Security #

Group #

Insured's Employer Name

Patient's Relationship To Insured

Secondary Insurance Information

Insurance Company Name

Insured's Name

First

Last

Insured's Date of Birth Ex: 01012021

Insurance Company's Address

Address Line 1

Address Line 2

City

State

Zip Code

Member ID # or Social Security #

Group #

Insured's Employer Name

Patient's Relationship To Insured

Employment Information

The Following Is For:

Employer Name

Occupation

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

I give my permission to release any protected information to the following people:

CONSENT FOR SERVICES

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. We require an appointment confirmation at least 24 hours in advance or your appointment could be cancelled. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed. Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. The undersigned hereby authorizes the release of any information relating to all claims for benefits submitted on behalf of myself and/or dependents. l further expressly agree and acknowledge that my signature on this document authorizes my dentist to submit claims for benefits for services to be rendered, without obtaining my signature on each and every claim to be submitted for myself and/or dependents, and that I will be bound by this signature as though the undersigned had personally signed the particular claim. I understand that the fee estimate listed for this dental care can only be extended for a period of 90 days from the date of the patient examination. In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. l further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form. I have read the above conditions of treatment and payment and agree to their content. By signing this, you understand and agree that it is our policy to scan original documents and store the documents in an electronic form. Further, you agree that any agreement bearing a scanned signature, which is printed from the electronic form, has the same force and effect as the original document.

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

HEALTH INSURANCE PORTABILITY ACCOUNTABILITY ACT (HIPAA), 1996

http://www.hhs.gov/programs/hipaa/index.html I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations. By signing this, you understand and agree that it is our policy to scan original documents and store the documents in an electronic form. Further, you agree that any agreement bearing a scanned signature, which is printed from the electronic form, has the same force and effect as the original document.

WRITTEN FINANCIAL POLICY

Thank you for choosing Higginbotham Family Dental. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.

Payment Options

You can choose from:

-Cash, Check, Visa, Mastercard, Discover Card, American Express or our Discount Dental Plan We offer a 5% discount to patients who do not have dental insurance and pay for their treatment in full with cash/check prior to completion of care for procedures over $300.
-There will be a $25 charge to your account for returned checks from your bank for any reason.
-Upon non-payment, if your account is sent to collections, we will charge a 10% collections/legal fee.
- NO INTEREST¹ Payment Plans² from CareCredit and In-house Financing
1. Allow you to pay over time with NO INTEREST¹
2. Convenient, low monthly payment plans² also available
3. No annual fees or pre-payment penalties

Please note: Higginbotham Family Dental requires payment prior to the beginning of your treatment. If you choose to discontinue care before treatment is complete, you will receive a refund less the cost of care received. For plans requiring multiple appointments, alternative payment arrangements may be provided. For patients with dental insurance we are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement for your treatment.³ However, the patient understands that the insurance is an agreement between the insured and the insurance company, not the insurance company and Higginbotham Family Dental. The patient also understands that they are responsible for their balance regardless of their insurance. If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need. I agree that the facility, Higginbotham Family Dental, or any other collection or servicing agency or agencies retained by the facility (together referred to hereafter as “collectors”) to collect any money that I owe to the facility may contact me by telephone or text message at any number given by me or otherwise associated with my account, including by not limited to, cellular/wireless telephone numbers which may result in my incurring fees for the call or text message. I understand, acknowledge and agree that the collectors may contact me by automatic dialing devices and through pre-recorded messages, artificial voice messages or voice mail messages. I further agree that the collectors may contact me using e-mail at any e-mail address I provide to the facility or is otherwise associated with my account. By signing this, you understand and agree that it is our policy to scan original documents and store the documents in an electronic form. Further, you agree that any agreement bearing a scanned signature, which is printed from the electronic form, has the same force and effect as the original document. Fee estimates are only valid for 90 days and are subject to change. ¹If paid within the promotional period. Otherwise, interest assessed from purchase date. Minimum monthly payment required. ²Subject to credit approval ³However, if we do not receive payment from your insurance carrier within 60 days, you will be responsible for payment of your treatment fees and collection of your benefits directly from your insurance carrier.

APPOINTMENT NO-SHOW/ LATE CANCELLATION POLICY

Dear Patient: We are so excited to have you as a patient, and would really appreciate you contacting us immediately if you are not able to make your scheduled appointment. We ask that you give us at least 24hr notice. This courtesy makes it possible to give your reserved time slot to another patient. Repeated cancellations, or 3 no shows/no-call appointments with a 12 month period, may result in loss of future appointments, or dismissal from our practice. By signing this, you understand and agree that it is our policy to scan original documents and store the documents in an electronic form. Further, you agree that any agreement bearing a scanned signature, which is printed from the electronic form, has the same force and effect as the original document. I give Higginbotham Family Dental to use any picture or video taken of myself at the office or at an event for their website or any of their social media platforms. I agree to let Higginbotham Family Dental do a soft credit pull when needed to see if I am eligible for their in-house financing to get my treatment started.

Signature of Applicant (Type Your Name) *

Date *

Name