Health History Form (Adult)

Please correct the errors described below.

Patient Information

Insurance Subscriber Information (if different from patient):

Medical History

Please check (Y) for "yes" or (N) for "no" for any of the following which may apply to you now or in the past:

Information Release/HIPAA

** this release of information will remain in effect until terminated by me in writing

Spouse Name and Number/Child(ren) Name and Number
Parent(s)/Guardian(s) Name

Financial Policy

The primary goal of our dental practice is to provide the highest quality oral health care in the most gentle, efficient and enthusiastic manner. Since our practice is also a business with obligations that must be met, we ask that all patients pay for their treatment in full on the day of each visit to our office unless prior arrangements have been made.

We accept cash, check, VISA, MasterCard, Discover and Care Credit. Payment of your “estimated” portion is due at the time services are rendered, such as your annual deductible and/or percentage of the treatment not covered by insurance. As a courtesy, we will gladly contact your insurance in order to provide an “estimate” of your patient portion. However, despite this, we cannot guarantee the payment of insurance benefits nor can we provide 100% accuracy of this estimated amount since many factors are involved that determine the actual payment of benefits once submitted and processed by your insurance. Keep in mind that many insurance companies base their quoted percentage of coverage (i.e 100%, 80%, 50%, etc.) on their own fee schedule and not our office’s actual fees, which may result in a balance due higher than expected. Should an outstanding balance due result after your insurance company processes your claim, you will then be sent a statement.

-Outstanding balances on your account are discouraged and must be cleared within 30 days of treatment. Amount due and not paid within 30 days will be charged interest at a rate of 1.5% per month or 18% annually.

-Payment Plans are accepted for treatment resulting in a higher balance for existing patients. Usually, we ask that you pay half down and then make monthly payments from there. If you are unable to make the agreed upon monthly payment, we ask that you make a payment. Letters will be sent out for late payments. If there is no payment for two consecutive months the account will be referred to Collections.

-Delinquent Balances over 90 days old will be referred to Collections. All referred accounts are marked “inactive”. In order to have your account “reactivated” and continue to receive dental treatment in our office, the delinquent balance must be paid in full. Only after the total account balance has been paid in full can appointments be made and your account and patient status be reactivated.

-A returned check fee of $30.00 (subject to change as bank fees increase) will be added to your account for any returned check. Before we accept another payment by check, the $30.00 fee plus full payment for the check that did not clear must be paid in cash, VISA, MasterCard, Discover or Care Credit.

-If an overpayment on your account occurs after insurance claims are processed, you may request a refund of the overpayment paid by you. All patient overpayments will be processed within 30 days of your request and after account reconciliation has occurred.

Signature: I understand and accept the financial and the dental insurance policies listed above and have had any and all questions answered to my satisfaction. I agree to pay for all treatment in a timely fashion as described so as to avoid additional fees. I hereby authorize my insurance benefits to be paid directly to McCoy Samples Mattingly Dental Clinic. I realize that I am responsible to pay for any deductible amount(s), my co-insurance portion and for any non-covered services. I understand that I am financially responsible for any and all charges of dental treatment and incurred fees, whether or not paid by said insurance and I agree to pay such charges in full. I also, hereby, authorize the release of pertinent medical/dental information to the insurance.

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