Dr. Chris Houser, D.M.D., P.C. - Heritage Hunt Dental

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Dental History

Do you currently have problems with any of the following (please select yes or no):

Do you have any of the following cosmetic concerns?

Any interest in the following cosmetic services?

Medical History

Please select yes or no whether you have had any of the following:

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DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Medical and Dental History Updates: Please review all above questions and note any changes below.

Patient’s Personal Information

Phone #’s:

Emergency Contact:

If completing this form for another person:

Person Responsible for Account (if different than patient)

Phone #'s:

Primary Insurance Subscriber and Carrier Information (if different than above):

Phone #'s:

Secondary Insurance Subscriber and Carrier Information (if different than above):

Phone #’s:

How did you hear about our office?

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Authorizations and Agreements

Appointments

Every appointment you schedule is reserved exclusively for you. There is a fee for failing to keep appointments. We understand that occasionally due to circumstances beyond your control it may be necessary to reschedule an appointment. We ask that you kindly give at least 24 hours notice for any appointment changes.

Patient Privacy

I have received a copy of this office’s “Notice of Privacy Practices” and consent to your use and disclosure of my protected health information to carry out treatment, payment activities (eg. in connection with insurance claims), healthcare operations, or when required by law. I understand my rights concerning my health information.

Financial Matters

Dr. Houser only places white/tooth-colored fillings (composite resin). Your insurance company may downgrade your benefit to the silver-mercury filling (amalgam) fee and you will be responsible for the difference in cost. Please initial here to acknowledge this.

Balances over 30 days past due will be subject to an interest charge of 1.5% per month each month that the payment is outstanding. The returned check fee is $75. In the event that this account is turned over to an attorney for collection, you agree to pay all collection costs including interest charges, attorney’s fees and court costs. We do realize that temporary financial problems may affect timely payment in some cases. We encourage open communication with our office in order to arrange mutually agreeable payment terms.

It is important for you to keep us informed of any changes in your employment and/or insurance. We will (in most cases) submit insurance claims for you. Any assistance in this matter does not imply any actual responsibility on our part. This is a courtesy we extend to you and, if necessary, will retract; thereby, making you responsible for all claims submissions. In this case, all fees (not just co-payments) would be due at the time services are rendered.

I authorize direct payment of dental benefits to Heritage Hunt Dental. I acknowledge that my signature on this document authorizes my doctor 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 my dependents, and that I will be bound by this signature as though the undersigned had personally signed the particular claims.

Payments for services rendered are due at time of service. I agree to make payment for all charges for dental services not paid for by my dental benefit plan (if applicable) at the time of service. If my insurance does not make payment to Heritage Hunt Dental within 30 days for the balance owed, I will take responsibility for payment.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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