Patient Registration Forms

If you have orthodontic coverage, my staff and I would like to help you use any insurance benefits available to you. If you do the following before you come to our office for your examination appointment, we will be able to process your claim quickly and efficiently.

  1. Please check with your employer’s insurance clerk and verify that you have orthodontic coverage. Your benefits depend on the contract your employer purchased from the insurance company. We have no way of knowing until the insurance company responds to the claim.
  2. If you have any orthodontic insurance, please fill out the insurance information sheet below.
  3. Please provide us with your insurance card so we can make a copy for your file.
  4. If more than one insurance company is involved, we need information for each one.
  5. If your insurance carrier changes or your insurance is terminated at any time, it is your responsibility to notify us. If your insurance is terminated, it is your responsibility to pay the balance.

You may access the following forms to assist us with your care. Please print and fill out the following forms, then bring them to your appointment.

New Patient Form (Child)

New Patient Form (Adult)

Dental Insurance Information Form

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At Hass Orthodontics, we do not want anything to get in the way of a perfect smile. We offer each and every patient we see a free smile assessment.

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