DRIVER'S LICENSE #
ARE YOU A FULL TIME COLLEGE STUDENT? NAME OF SCHOOL AND CITY
DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING?
LOW BLOOD SUGAR
HAY FEVER, ALLERGIES
ARE YOU PREGNANT
MITRAL VALVE PROLAPSE
HIGH BLOOD PRESSURE
EPILEPSY / SEIZURE
FAINTING / BLACKOUTS
LOW BLOOD PRESSURE
HEART VALVE REPLACEMENT
FACIAL / HEAD INJURY
HEADACHE / MIGRAINES
SEVERE SPINAL STENOSIS
GLAUCOMA / EYE PROBLEMS
DO YOU HAVE ANY OTHER DISEASES OR CONDITIONS NOT LISTED ABOVE? IF YES PLEASE LIST:
DO YOU HAVE ALLERGIES TO ANY OF THE FOLLOWING? PLEASE CHECK ALL THAT APPLY
LIST ALL MEDICATIONS CURRENTLY BEING TAKEN OR A PRINTED COPY OF YOUR LIST:
NAME OF PHYSICIAN:
PHONE OF PHYSICIAN:
HAVE YOU BEEN HOSPITALIZED IN THE LAST YEAR? IF YES, PLEASE EXPLAIN
HAVE YOU NOTICED ANY OF THE FOLLOWING?
DISCOMFORT IN FACE, HEAD, NECK, JAW
JAW CLICKING OR POPPING
SWELLING OR LUMPS IN MOUTH
FOOD CAUGHT BETWEEN TEETH
BLEEDING OR SORE GUMS
SENSITIVITY TO SWEETS, HOT OR COLD
RECURRING SORE IN OR AROUND MOUTH
TEETH TENDER TO CHEWING
I hereby authorize Chase Hall, DMD to take radiographic X-rays (1 Panorex every 5 years and 4 Bitewing Xrays 1 time per year), study models, photographs or any other diagnostic aid deemed necessary to make a thorough diagnosis for my dental care. I also authorize the doctor to prescribe necessary forms of medication, and to perform any treatment that may be indicated and agreed upon regarding my dental care.
I understand my rights to privacy regarding my protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to provide and coordinate my treatment among consulting health/dental care providers who may be involved in that treatment directly and indirectly. I further authorize the release of any information regarding the diagnosis and records of treatment to my insurance company. The release of such information to the insurance company is solely for the purpose of facilitating the billing and reimbursement of treatment directly to the dentist for insurance benefits under which I am entitled. I understand the responsibility for payment of services rendered for myself and my family are due and payable at the time the services are performed.
I also give my consent to receive emails and text messages from Hall Family Dental Care regarding appointment reminders and other correspondence regarding my dental care.
Under the requirements for HIPAA we are not allowed to give your protected health information to anyone without your consent. If you wish to have a family member or someone close to you have access to your private health information, please indicate below.
You May Disclose My Information To The Following
Do Not Disclose My Information To Anyone But Me
Relationship to Patient:
Relationship to Patient:
MY SIGNATURE CONFIRMS THAT I UNDERSTAND ALL HIPAA, FINANCIAL AND COMMUNICATION POLICIES AS OUTLINED ABOVE AND THAT THE HEALTH AND DENTAL INFORMATION THAT I HAVE PROVIDED IS CORRECT TO THE BEST OF MY KNOWLEDGE.
SIGNATURE OF PATIENT OR RESPONSIBLE PARTY:
At Hall Family Dental Care, we believe that you deserve excellent health care. That is why we always present you with the best dental solutions to treat your personal situation. Each year we provide outstanding dental care to thousands of patients, each with unique financial concerns and needs. This information is meant to help answer frequent questions regarding payment for dental care. Please do not hesitate to contact one of our team members if you need additional information.
We welcome you to our family and look forward to helping you get the healthy, beautiful smile that you have always wanted. If there is anything we can do to make your visits here more pleasant, please do not hesitate to ask one of our team members to assist you.
Dr Chase Hall and The Team
Dental Insurance Information:
Name of Insurance Company:
Ins Phone #:
Subscriber's Social Security #:
If you have secondary insurance (more than one dental insurance for your family) we are happy to file it for you, however the payment will go directly to you. Therefore, you will be responsible for any balance incurred after the primary insurance has paid.
Payment at time of service:
Hall Family Dental Care requires payment in full for
at the time of service. We accept multiple forms of payment, which include Mastercard, Visa, American Express, Discover, HSA Card, Cash and Checks. If you need an extended finance option, we also work with Care Credit, which offers same as cash options designed to meet your treatment plan needs on approved credit. Please ask one of our team members for an application or visit www.carecredit.com.
About Dental Insurance:
If you have dental benefits, congratulations! You are truly fortunate. Your dental benefits are based upon a contract made between your employer and an insurance company.
If you have any questions regarding your dental benefits, please contact your employer or insurance company directly.
Dental benefit plans will never totally pay for completion of your dental care. It is only meant to assist you. We currently file all private care insurance plans (plans that do not require you to select a dentist from a list or require our office to accept a reduced fee for service).
We estimate your portion based on the most up to date information we have, but it is
ONLY AN ESTIMATE.
If you would like to know your exact insurance benefit for a certain procedure, we will be happy to file a "pre-treatment authorization" with your insurance company prior to treatment. This does delay treatment but will give you the exact out-of-pocket figures you may require.
Many people receive notification from their insurance company that dental fees are "above usual and customary." An insurance company determines their reimbursement level by surveying a geographic area, calculating the average fee, and then determining that 80% of the average fee is customary. Included in this survey are discounted dental clinics and managed care facilities, which have severely reduced dental fees that bring down the average. Any doctor in private practice will have fees that insurance companies define as "higher than usual and customary."
We bill your insurance as a courtesy. Hall Family Dental Care is
contracted or "In Network" with any Insurance Companies. If insurance does not pay within 90 days, Hall Family Dental Care reserves the right to request payment in full for services rendered. Insurance payment would then go directly to you. This rarely happens, but it is important that you recognize that the insurance you have is a legal contract between
and your insurance company. In order to continue to provide the outstanding dental care our patients deserve we are not and cannot be a part of that legal contract. Ultimately, you are responsible for all charges incurred in our office.
A specific amount of time is reserved especially for you, and we strongly encourage all patients to keep their appointments. If you must change your appointment, we kindly request at least
notice to avoid a $35/hour cancellation fee (emergencies are an exception). After multiple cancellations, we will require pre-payment for services in our office.
My signature confirms that I understand the Financial Policy of Hall Family Dental Care as outlined above.
Signature of Patient or Responsible Party:
Please enter code above in the field below.