AESTHETIC AND IMPLANT DENTISTRY OF NORTH ALABAMA
Dr. William L. Ingram V, DMD, MAGD, LLC
Master, Academy of General Dentistry
2227 Drake Ave. SW
Suite 10-B
Huntsville, AL 35805

Tel: 256-883-7832 or 256-881-0985
Fax: 256-882-6629
Email: info@drwilliamingram.com

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Please print these forms and bring to your first appointment.

Patient Information Form

Patient Dental History Form

Patient Medical History Form 		Insurance Policies

It is the patient's responsibility to provide us with proper insurance information. This includes any primary and secondary insurers. You must provide all requested information for both parties including a copy of the insurance card, current address, social security number or insurance id number, date of birth, and employer.

We will gladly submit your insurance claims. Although we file insurance claims as a courtesy to you, you are still responsible for payment of services regardless of the amount your insurance pays. If there is a balance after your insurance has paid, you have 30 days to make payment on the invoice.

If your insurance company is not contracted with us, you agree to pay any portion of the charges not covered by insurance, including but not limited to those charges that are above the usual and customary allowance. If we are out of network for your insurance company and your insurance pays you directly, you are responsible for payment and agree to forward payment to us immediately.

Insurance claims that remain unpaid after 90 days will become patient responsibility.
Please Come Prepared!

New patients must present a proof of identification (ie Driver's License) at first visit. Also, please present your insurance card if using insurance. It is every patient's responsibility to come to their appointment prepared with the proper documents!

If you are taking medications, please bring a list of the medications with you.
Payments accepted:
  • Cash
  • Check
  • Visa
  • Master Card
  • Discover
  • Money Order
  • Care Credit
Financial Policies
Payment is expected at time of service. If we are filing insurance for you, then monthly statements will be sent after insurance has made determination on claims or other charges are incurred. We can accept payments over the phone using Visa, MasterCard, Discover, or a debit card.

Patients over 18 years of age receiving treatment are responsible for payment of service, regardless of any personal arrangements outside of the office.

Accounts that are past due over 120 days will be sent to an outside collection agency. At that point, the account is out of our hands.

Financial Responsibility
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Dr. William L. Ingram V, DMD, MAGD, LLC
2227 Drake Ave. SW Suite 10-B Huntsville, AL 35805
Tel: 256-883-7832 or 256-881-0985 Fax: 256-882-6629


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