1214 Murfreesboro Road, Suite 210 • Franklin, TN 37064 • Tel: (615) 794-2444 Fax: (615) 794-2049 • E-mail: [email protected] • www.jareynoldsdds.com Welcome!We are dedicated to the concept that all people have the opportunity to retain their teeth throughout their lifetime with optimum health, function, comfort and esthetics. We realize the importance of your smile and are committed to offering the best that dentistry has to offer—providing quality restorative dentistry with special emphasis on cosmetics. Thanks for coming.
Patient information
Last Name
Names of family members who use our servicesWho referred you to our office? in Case emergenCy
Closest friend or relative (not living with you)
Home Phone (
insuranCe information
Name of Subscriber (Name insurance is listed in.)
Subscriber’s Birth Date
Subscriber’s Address Subscriber’s Employer Patient’s relationship to insured: ❑ Self ❑ Spouse ❑ Child ❑ OtherInsurance Plan Name Delta Dental Policy: Dr. Reynolds is considered an “out-of-network” provider with ALL insurance companies due to our “out-of-network” status, Delta Dental has informed us all re-imbursements wil be sent to the subscriber. This means your insurance company wil mail payments directly to you. In order to simplify the filing process we ask that you provide us with your dental insurance information. This wil give us the ability to print a claim and you (the patient) are not required to fil out any extra forms. To receive your re-imbursement you wil simply mail the insurance claim form to the insurance company. They will process your claim and send payment to you. NOTE: Patients using Delta Dental insurance are required to pay in full at the time of their visit. Insurance Plan Address for DENTAL claimsCity Do you have a secondary insurance plan? ❑ Yes ❑ No aCCount information
Guarantor of Account
Address (if different from above)
How will payment of your account be handled? ❑ Cash
We file insurance as a courtesy to our patients. However, we are not considered in-network providers for any insurance plan. We will be considered an out-of-network provider. Verification of coverage and benefits is the responsibility of the patient.
We allow 60 days for insurance to reimburse for treatment. Any balance after the 60 day grace period becomes the patient’s responsibility. If any claim expires due to inaccurate information or non-current information, the balance becomes the patient’s responsibility. Any re-submissions to the insurance company will be carried out by the patient.
secondary insurancy:
Our office does not file secondary insurance. This is the responsibility of the patient. When estimating patient portions
secondary insurance will not be calculated in determining your payment due. However, we will provide you will the
necessary paperwork in order to make filing your claim more convenient.
How to file the claim. . .
As a courtesy, we will provide you with a completed secondary insurance claim form. Once you receive the Explanation
of Benefits (EOB) from your primary insurance carrier you will have all materials needed to submit to your secondary
insurance carrier. Simply attach a copy of the primary EOB to the secondary claim form and submit to the claims mailing
address (found in upper right-hand corner of claim form).
your reimbursement. . .
In most cases you should receive your reimbursement within two to four weeks of the date that you submit the claim.
If you haven’t received it by that time, contact your insurance representative to find out why.
I understand that the financial responsibility for dental services provided in this office for myself and/or my dependents is mine.
I further understand that a finance charge may be added to any past due balance. In the event of default. I (we) promise to
pay legal interest on the indebtedness, together with such collection costs and reasonable attorney fees as may be required
to effect collection of this note.
1214 Murfreesboro Road, Suite 210 • Franklin, TN 37064 • Tel: (615) 794-2444 Fax: (615) 794-2049 • E-mail: [email protected] • www.jareynoldsdds.com DEntal HIStORY (for adults 18yrs or older)Last Name Date of last cleaning and exam?Have you ever had: ❑ Orthodontics if so, were you a ❑ Child or ❑ Adult; ❑ Periodontal (Gum) Surgery; or Why have you come to JA Reynolds DDS? Please explain Are you dissatisfied with any previous dentistry service you have had? ❑ Yes ❑ No If yes, why? Do you use tobacco? ❑ Cigarettes ❑ Smokeless TobaccoDo you have any areas where food impacts around your teeth? ❑ Yes ❑ NoDo your gums tend to: ❑ Bleed Easily ❑ Feel Tender ❑ IrritatedAre your teeth sensitive to: ❑ Hot ❑ Cold ❑ Pressure ❑ SweetsDo you have pain in your: ❑ Head ❑ Neck ❑ Shoulder ❑ Upper BackDo you have any: ❑ Popping ❑ Clicking ❑ Other noises in your jaw jointsAre you aware of: ❑ Grinding Your Teeth ❑ Clenching Your TeethList any other problems you may be having: Have you ever had local anesthetic (novocaine) for dental purposes? Have you ever had nitrous oxide (laughing gas)? Have you ever had any negative reactions to a dental injection or nitrous oxide? Have you ever been anxious or nervous about dental treatment? CosmetiCs
What would you like to do to improve your smile? ❑ Whiten Teeth ❑ Straighten Teeth ❑ Change Size/Shape
mediCal History
Physician’s Name
Are you being treated by a physician presently? If so, for what Have you ever required hospitalization? If so, for what? Are you prone to dizziness or fainting spells? for Women only
Are you pregnant? If so, when are you due? Are you presently taking birth control pills? Personal History (check all that apply)
mediCal History
Are you taking any medications? If so, list below Thank you for your cooperation. If there is any other information which you feel would be a value, please let us know.
Consent for use and disClosure of HealtH information
By signing this form you will consent to our use and disclosure of protected health information to carry out treatment,
payment activities, and healthcare operations.
I understand that the information above is necessary to provide me with dental care in a safe and efficient manner. To my knowledge answers are correct and complete. Realizing that the use of anesthetic agents embodies certain risks. I will inform this office of any changes in my medical history.
I further authorize and consent that Dr. Reynolds and/or his assigned may utilize diagnostic aids deemed appropriate and preform all forms of treatment, medication, and therapy deemed necessary in connection with the dental care of (name of patient) until written notice is given discontinuing this permission.

Source: http://lxia.viviotech.net/jareynoldsdds.com/pdf_files/DentalHistory_form.pdf

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