New Patient Forms


 

To expedite your first visit, please print these forms and fill them out completely. You may fax (317-581-0219) or email (drjhartman@aol.com) them to our office prior to your appointment or bring them with you along with a copy of the front and back of your insurance card.

New Patient Form (Adult)

New Patient Form (Child)

HIPPA Privacy Practices Form

 

Thank you for choosing Hartman Dentistry for your dental needs. We do our absolute best to help you understand and estimate your insurance benefits. As a courtesy, our office will verify your insurance with your insurance carrier upon request as long as you provide us with your up-to-date and correct insurance information, no less than 1 business day before your appointment.

Due to the thousands of insurance plans we ask that you know your benefits for it would be impossible for us to know them all. Each insurance plan is unique in what services they will allow. Please be aware that your dental insurance plan is a contract between you and the insurance company or between you, your employer and the insurance company. It is your responsibility to know the benefits, limitations and exclusions of your dental plan.

We are not responsible, nor can we guarantee, how your insurance carrier will pay on a claim. We will collect your estimated portion on the date of your appointment. Once the insurance carrier has paid their portion, the remaining balance will become your responsibility.

Location
John H. Hartman DDS
3091 E 98th Street, Suite 220
Indianapolis, IN 46280
Phone: 317-266-9342
Fax: 317-581-0219
Office Hours

Get in touch

317-266-9342