PATIENT REGISTRATION Today’s Date: PATIENT INFORMATION Last Name: First Name: MI: Preferred Name/Nickname (if different from above): Date of Birth: SS#: MALE FEMALE Ethnicity: Home Address: STREET CITY STATE ZIP Home Phone: Cell Phone: Names and ages of other children in the family: Who has legal custody of the patient? School: Grade: Preferred Language: PARENT/GUARDIAN INFORMATION Last Name: First Name: MI: Relationship to patient: MALE FEMALE Marital Status: Divorced Married Single Widowed Date of Birth: SS#: Phone: Occupation: Address (if different from child: STREET CITY STATE ZIP Email address: PARENT/GUARDIAN INFORMATION Last Name: First Name: MI: Relationship to patient: MALE FEMALE Marital Status: Divorced Married Single Widowed Date of Birth: SS#: Phone: Occupation: Address (if different from child: STREET CITY STATE ZIP Email address: INSURANCE Name of Insured: Relationship to child: Insured Birth Date: Insured SS#: Insured’s Employer: Insurance Company Name: Insurance Company Phone #: Insurance Company Address: Group Number: ID Number: Signature of Responsible Party (Parent/Legal Guardian) Printed Name: Relationship to Patient: Date:
Transcript
PATIENT REGISTRATION
Today’s Date:
PATIENT INFORMATION Last Name: First Name: MI: Preferred Name/Nickname (if different from above): Date of Birth: SS#: MALE FEMALE Ethnicity: Home Address:
STREET
CITY STATE ZIP
Home Phone: Cell Phone: Names and ages of other children in the family: Who has legal custody of the patient? School: Grade: Preferred Language:
PARENT/GUARDIAN INFORMATION Last Name: First Name: MI: Relationship to patient: MALE FEMALE
Marital Status: Divorced Married Single Widowed Date of Birth: SS#: Phone: Occupation: Address (if different from child:
STREET
CITY STATE ZIP
Email address:
PARENT/GUARDIAN INFORMATION Last Name: First Name: MI: Relationship to patient: MALE FEMALE
Marital Status: Divorced Married Single Widowed Date of Birth: SS#: Phone: Occupation: Address (if different from child:
STREET
CITY STATE ZIP
Email address:
INSURANCE Name of Insured:
Relationship to child:
Insured Birth Date: Insured SS#:
Insured’s Employer:
Insurance Company Name: Insurance Company Phone #:
Insurance Company Address:
Group Number: ID Number:
Signature of Responsible Party (Parent/Legal Guardian) Printed Name: Relationship to Patient: Date:
PEDIATRIC MEDICAL HISTORY
Date of Birth:
Office Phone:
Name of Child:
Name of Child’s Physician: Date/Reason for last visit to Physician’s office: Are vaccinations current? Yes No Is your child in good health? Yes No Has your child ever had a health problem? Yes No If yes, explain
Allergies / Adverse drug reactions: Yes No
If yes, explain
Does your child have an allergy to latex? Yes No
Is your child taking any medication (prescription or over the counter), vitamins, or dietary supplements? Yes No List name, dose, frequency and date started:
Does your child have any special needs? Yes No If yes, please explain Has your child ever been hospitalized, had surgery, or had an emergency room visit? Yes No If yes, list date and describe Has your child ever had sedation or general anesthesia? Yes No If yes, explain
Has your child ever had problems with or been treated by a doctor for any of the following? Please check all that apply and provide details below:
Please review the above items carefully, and check here if none of the above conditions apply to your child
Please provide details here for items checked above:
I understand that the information that I have given is correct and accurate to the best of my knowledge, that it will be held in the strictest of confidence, and it is my responsibility to inform this office of any changes in my child’s medical status. I also authorize the dental staff to perform the necessary dental services my child may need.
Signature of Responsible Party (Parent/Legal Guardian): Printed Name: Relationship to Patient: Date:
PEDIATRIC DENTAL HISTORY
Date of Birth: Name of Child: What is your primary dental concern about your child?
Has your child ever been to the dentist? Yes No Date of last X-rays (if taken):
Name of dentist and date of visit: Has your child ever had any complications following dental treatment? Yes No
If yes, please explain Does your child suck a finger, thumb or pacifier? Yes No Does your child clench or grind his/her teeth? Yes No Does your child bite his/her nails? Yes No Is your child having problems any of the following? (Please check)
- Breast fed Yes No At what age stopped?- Bottle fed Yes No At what age stopped?
Does your child sleep with a bottle or nurse all night? Yes No Please describe dietary habits including meals, snacks, drinks, etc. Is your child drinking fluoridated water? Yes No Is your child taking fluoride supplements? Yes No Does your child use fluoride toothpaste? Yes No Does your child brush his/her teeth daily? Yes No Who brushes ? Does your child floss daily? Yes No Has your child had any injury to the teeth, jaws, or face? Yes No
If yes, please explain Has your child inherited any family dental characteristics? Do you think your child will cooperate for dental treatment? Has your child ever had: Nitrous oxide/”laughing gas” sedation general anesthesia
Please explain Are you aware that some children may cry, yell, or move around during dental treatment?
If so, do you have any concerns or questions about this? Please indicate any other dental concerns here:
How did you hear about us? Dentist referral -- Whom may we thank for referring you to our practice? Website Google Patient referral -- If so, by whom?
Signature of Parent/Guardian: Printed Name: Relationship to Patient: Date:
APPOINTMENT POLICY
A scheduled appointment is reserved specifically for your child. Any change in this appointment affects many people. We understand that circumstances change and an unexpected commitment can affect/alter daily plans. Please let us know as soon as possible (we kindly ask for at least 24 hours in advance) if you need to reschedule your child’s appointment so that another family waiting for treatment can be seen.
If your child is a new patient to our office, please plan to arrive 30 minutes prior to your scheduled initial visit appointment so that we may collect insurance information and complete any additional paperwork that may be necessary in order for us to provide treatment for your child.
If you arrive 10-15 minutes late for any appointment, you may be asked to reschedule your appointment for the next available appointment time.
If an appointment is missed and we do not hear from the Responsible Party (Parent/Legal Guardian), our office will log a “failed appointment” on the account. If cancellations with less than 24 hours notice occur, our office will log a “cancellation” on the account. Three missed/failed appointments or three cancellations with less than 24 hours notice will result in being dismissed from the practice.
We strive to see all patients on time for their scheduled appointment. At times our office schedule may be delayed in order to accommodate a child in a dental emergency situation. Please accept our apology in advance should this occur during your child’s appointment time. If your child is in need of emergency treatment, we will extend the same promptness of treatment for him/her.
I affirm that my signature represents my agreement to all the above-mentioned terms.
Signature of Responsible Party (Parent/Legal Guardian):
Printed Name:
Relationship to Patient: Date:
CONSENT FOR TREATMENT
As responsible party for (Patient name) , I hereby give consent for the following dental treatments and evaluations to be performed by the Dental Professionals at Pediatric Dentistry of the Ozarks, LLC.
• Cleaning• Fluoride treatment• X-rays for diagnosis and evaluation• Fillings• Extractions• Crowns or “caps”• Nitrous Oxide or “laughing gas” (utilized for patient comfort)• Space maintainers• Nerve treatment / Pulpotomy• Administration of dental anesthetic
I understand that should the patient become uncooperative during dental procedures with the movement of the head/arms and/or legs, dental treatment cannot be safely provided. During such behavior, it may be necessary for the assistant to hold the patient’s hands, stabilize the head and/or control leg movements. Should the patient become uncooperative during dental treatment with excessive body movements, it may be recommended that the patient be stabilized using a “papoose board” to prevent injury and enable Dental Professionals to safely provide necessary treatment. The parent/legal guardian’s consent will be obtained prior to initiation of “papoose board” stabilization.
I understand that treatment for children includes efforts to guide their behavior by helping them understand the treatment in terms appropriate for their age. Behavior will be guided using praise, explanation and demonstration of procedures and instruments, using variable voice tone.
The usual and most frequent risks or complications occurring from the planned treatment and procedures also have been explained to me. These risks include but are not limited to, the possibility of pain or discomfort during the treatment, swelling, infection, bleeding, injury to adjacent teeth and surrounding tissue, development of a temporomandibular joint disorder, temporary or permanent numbness, and allergic reactions.
I understand that during the course of the patient’s dental treatment, something unexpected may arise that may necessitate procedures in addition to or different from those listed on the patient’s plan of care and that I will be consulted prior to initiation of treatment procedures not listed in the patient’s treatment plan. I am aware that the practice of dentistry is not an exact science and acknowledge that no guarantees have been made to me concerning the results of the dental treatment that the patient receives in this office.
I agree to allow the Office to test for infectious diseases including hepatitis and human immunodeficiency virus (HIV) and that these tests may be ordered if one of my care givers is exposed to patient blood or body fluid.
CONSENT FOR TREATMENT
I understand that I may revoke this consent to treatment at any time and that no further action based on this consent will be initiated except to the extent that treatment and procedures have already been performed or initiated. Any revocation of this consent must be received in writing.
I have carefully read this form and understand all of its contents. All of my questions have been answered to my satisfaction and I authorize the dental staff of Pediatric Dentistry of the Ozarks to perform the necessary dental services my child may need.
Signature of Responsible Party (Parent/Legal Guardian): Printed Name: Relationship to Patient: Date:
FINANCIAL POLICY AND AGREEMENT
As a courtesy to our patients, our office will file the dental insurance claim for treatment on your behalf. We will do our best to verify your policy and help you estimate and maximize your benefits. All relevant cards and forms for your insurance will need to be provided to our office in order to provide this service. Please understand the following regarding “dental insurance”…
Dental insurance usually does NOT cover 100% of the cost of treatment, and instead may be thought of as a “benefit” to be used to aid in treatment cost. There is no direct relationship between our office and your insurance company. An insurance policy is a contract between the patient and the insurance carrier. The specific plan chosen by you and/or your employer determines your insurance benefits, and our office has no control over the terms of your contract or benefit amounts. The portion of coverage given by a dental insurance company is only an estimate. Insurance companies will not release the exact amount they will pay for a procedure until the treatment is completed and the claim is submitted.
Any co-pay or account balance is due and payable at the time of service, unless other arrangements have been previously made with the financial manager at our office. We accept cash, personal check (which may not be post-dated, and must be accompanied by photo ID), MasterCard, Visa, Discover, or Care Credit. We understand that some families may have multiple people sharing responsibility for a child. Our office does not mediate between parties in the event that a dispute should arise. The undersigned accepts ultimate responsibility for the child. Our office will collect from this person, regardless of a divorce decree. We request that outstanding account balances be paid within 30 days unless prior arrangements have been made with our office. Any balance 60 days or over will be subject to 1.5% per month (APR 18%) finance charge. Any account balances after 90 days are subject to review for professional collection. In the event that this account is referred to a collection agency, the undersigned agrees to pay the account balance in addition to a 30% collection fee and/or any attorney fees that are incurred. Thank you in advance for your understanding of our office financial policy. Your cooperation with this matter is greatly appreciated. Please let our office know if you have any questions regarding this policy, as we want you to be comfortable with the investment you are making in your child’s health. If you have any questions regarding your insurance, please contact your insurance company to verify the terms of your contract. I have read the above statements and understand that I am financially responsible for any and all charges incurred for services rendered by Pediatric Dentistry of the Ozarks, LLC, regardless of insurance claim status. I hereby authorize the payment of Insurance Benefits directly to Pediatric Dentistry of the Ozarks, LLC otherwise payable to me if my insurance carrier takes assignment of benefits. Signature of Responsible Party (Parent/Legal Guardian): Printed Name: Relationship to Patient: Date: Address of Responsible Party: City: State: Zip:
OFFICE POLICIES
A legal guardian must be present for the child’s initial patient visit in our office. A legal guardian must also fill out the new patient forms for the child (including medical history, dental history, etc). We prefer that a parent, legal guardian or custodial caregiver accompany your child to all visits. If an adult other than you will bring your child to subsequent visits, it is necessary to have a signed permission form from our office on file prior to the child returning to our office for additional treatment. This letter or signed release provides the accompanying adult permission to make dental decisions for your child on your behalf. Also, please inform us ahead of time if you will not be able to accompany your child.
Parents are welcome and encouraged to share in the initial visit by joining the child for their cleaning and exam. We hope that you will become comfortable enough to allow your child to enter the treatment area by themselves on subsequent visits. Children are encouraged to come back for their restorative procedures on their own to facilitate the doctor patient relationship. If a parent/guardian does accompany the patient into the treatment area for restorative care, we ask that they please act as a “silent & supportive observer.” This helps our dental team to establish trust and cooperation directly with your child.
All treatment plans and financial responsibilities will be discussed with the Responsible Party (Parent/Legal Guardian) prior to beginning treatment. As noted in the financial policy, all fees are due and payable at the time of service.
We please ask that only 2 adults accompany a child at one time to help ensure the safety and privacy of others.
If you choose to bring siblings to the patient’s appointment, we may ask that you please remain in the reception area while we see your child. This is again so that we may focus on providing quality care for your child.
We ask that you please refrain from cell phone use while in the clinical area.
No food and drink are allowed in the clinical area to help our office maintain standards of infection control and prevent any contamination of office products.
I affirm that my signature represents my agreement to all the above-mentioned terms.
Signature of Responsible Party (Parent/Legal Guardian):
Printed Name:
Relationship to Patient: Date:
PERMISSION TO SPEAK WITH OTHERS
This form is to be used for providing your authorization for our office to speak with designated authorized individuals (family, caretakers, etc.) about your child’s dental treatment under HIPPA.
Anyone not listed on this form will not be provided any information about your child.
PATIENT INFORMATION: Please list the patient(s) whose information is to be disclosed:
Patient: Date of Birth:
Date of Birth:
Date of Birth:
Date of Birth:
Date of Birth:
Patient:
Patient:
Patient:
Patient:
Patient: Date of Birth:
Address: STREET
CITY STATE ZIP
PERMISSION TO SPEAK WITH SECTION: The person(s) listed below has permission to discuss the treatment and care of the above named patient(s).
Date of Birth:
Phone #:
Date of Birth:
Phone #:
Date of Birth:
1. Name:
Relationship:
2. Name:
Relationship:
3. Name:
Relationship: Phone #:
This section to be completed by the Patient’s Guardian: By signing this form, I am confirming my authorization that Pediatric Dentistry of the Ozarks may use and disclose my child’s protected health information to the persons named on this form. I understand that this permission may be revoked at my request at any time by contacting us.
Date of Birth: Parent/Guardian Signature: Parent/Guardian Printed Name: Relationship to Patient: Date:
Notice of Privacy Practices
This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. We reserve the right to change our privacy practices and terms in this Notice at any time, provided such changes are permitted by applicable law, and to make new Notice provisions effective for all protected health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request. You may request a copy of our Notice at any time.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU We may use and disclose your health information for different purposes, including treatment, payment, and health care operations. For each of these categories, we have provided a description and an example. Some information, such as HIV-related information, genetic information, alcohol and/or substance abuse records, and mental health records may be entitled to special confidentiality protections under applicable state or federal law. We will abide by these special protections as they pertain to applicable cases involving these types of records. TREATMENT: We may use and disclose your health information for your treatment. For example, we may disclose your health information to a specialist providing treatment to you. PAYMENT: We may use and disclose your health information to obtain reimbursement for the treatment and services you receive from us or another entity involved with your care. Payment activities include billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your dental health plan containing certain health information. HEALTHCARE OPERATIONS: We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, conducting training programs, and licensing activities. INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE: We may disclose your health information to your family or friends or any other individual identified by you when they are involved in your care or in the payment for your care. Additionally, we may disclose information about you to a patient representative. If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information. DISASTER RELIEF: We may use or disclose your health information to assist in disaster relief efforts. REQUIRED BY LAW: We may use or disclose your health information when we are required to do so by law. PUBLIC HEALTH ACTIVITIES: We may disclose your health information for public health activities, including disclosures to: prevent or control disease, injury or disability; report child abuse or neglect; report reactions to medications or problems with products or devices; notify a person of a recall, repair or replacement of products or devices; notify a person who may have been exposed to a disease or condition; or notify the appropriate government authority if we believe a patient has been a victim of abuse, neglect, or domestic violence. NATIONAL SECURITY: We may disclose to military authorities the health information of armed forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody the protected health information of an inmate or patient. SECRETARY OF HHS: We will disclose your health information to the Secretary of the US Department of Health and Human Services when required to investigate or determine compliance with HIPPA. WORKER’S COMPENSATION: We may disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.
Notice of Privacy Practices
LAW ENFORCEMENT: We may disclose your PHI for law enforcement purposes as permitted by HIPPA, as required by law, or in response to a subpoena or court order. HEALTH OVERSIGHT ACTIVITIES: We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for the government to monitor the health care system, government programs and compliance with civil rights laws. JUDICIAL AND ADMINISTRATIVE PROCEEDINGS: If you are involved in a lawsuit or dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discover request, or other lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about the request to obtain an order protecting the information requested. RESEARCH: We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information. CORONERS, MEDICAL EXAMINERS, AND FUNERAL DIRECTORS: We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties. FUNDRAISING: We may contact you to provide you with information about our sponsored activities, including fundraising programs, as permitted by applicable law. If you do not wish to receive such information from us, you may opt out of receiving the communications. OTHER USES AND DISCLOSURES OF PHI: Your authorization is required, with few exceptions, for disclosure of psychotherapy notes, use or disclosure of PHI for marketing, and for the sale of PHI. We will also obtain your written authorization before using or disclosing your PHI for purposes other than those provided for in this Notice (or as otherwise permitted or required by law). You may revoke authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization.
YOUR HEALTH INFORMATION RIGHTS ACCESS: You have the right to look at or get copies of your health information, with limited exceptions. You must make the request in writing. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice. If you request information that we maintain electronically, you have the right to an electronic copy. We will use the form and format you request if readily producible. We will charge you a reasonable cost-based fee for the cost of supplies and labor of copying, and for postage if you want copies mailed to you. Contact us using the information listed at the end of this Notice for an explanation of our fee structures. If you are denied a request for access, you have the right to have the denial reviewed in accordance with the requirements of applicable law. DISCLOSURE ACCOUNTING: With the exception of certain disclosures, you have the right to receive an accounting of disclosures of your health information in accordance with applicable laws and regulations. To request an accounting of disclosures of your health information, you must submit your request in writing to the Privacy Official. If you request this accounting more than once in a 12 month period, we may charge you a reasonable, cost-based fee for responding to the additional requests. RIGHT TO REQUEST A RESTRICTION: You have the right to request additional restrictions to our use or disclosure of your PHI by submitting a written request to the Privacy Official. Your written request must include (1) what information you want to limit, (2) whether you want to limit our use, disclosure or both, and (3) to whom you want the limits to apply. We are not required to agree to your request except in the case where the disclosure is to a health plan for purposes of carrying out payment or health care operations, and the information pertains solely to a health care item or service for which you, or a person on your behalf (other than the health plan), has paid our practice in full. ALTERNATIVE COMMUNICATION: You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. We will accommodate all reasonable requests.
Notice of Privacy Practices
However, if we are unable to contact you using the ways or locations you have requested we may contact you using the information we have. AMENDMENT: You have the right to request that we amend your health information. Your request must be in writing and it must explain why the information should be amended. We may deny your request under certain circumstances. If we agree to your request, we will amend your record(s) and notify you of such. If we deny your request for an amendment, we will provide you with a written explanation of why we denied it and explain your rights. RIGHT TO NOTIFICATION OF BREACH: You will receive notifications of breaches of your unsecured protected health information as required by law. ELECTRONIC NOTICE: You may receive a paper copy of this Notice upon request, even if you have agreed to receive this Notice electronically on our website or by electronic mail (email). APPOINTMENT REMINDERS: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, post cards, or letters).
QUESTIONS AND COMPLAINTS If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or if you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the US Department of Health and Human Services. We will provide you with the address to file your complaint with the US Department of Health and Human Services upon request.
We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the US Department of Health and Human Services.
Contact information: Pediatric Dentistry of the Ozarks Privacy Officer Phone: 573.368.7336, Fax: 573.368.4FAX Address: 206 S Bishop Ave, Unit A, Rolla, MO 65401 Email: [email protected] , [email protected]
I have reviewed the Privacy Practices for this office.
I authorize release of any information concerning my (or my child’s) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I authorize release of any information concerning my (or my child’s) health care, advice and treatment to another dentist.
Signature of Responsible Party (Parent/Legal Guardian): Printed Name: Relationship to Patient: Date:
ASSIGNMENT OF BENEFITS AGREEMENT
Our office will accept an assignment of benefits from your insurance company with the following provisions. It is important to understand, dental insurance usually does NOT cover 100% of the cost of treatment, and instead may be thought of as a “benefit” to be used to aid in treatment cost. There is no direct relationship between our office and your insurance company. The contract regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for treatment, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies:
• Although we are willing to complete insurance information forms and submit a claim on your behalf, we do not accept responsibility for the outcome of the transaction. Completing insurance forms is a courtesy we extend to you in an effort to maximize your insurance reimbursement. By having our office process your insurance forms, it is important that you understand that this does not eliminate your financial obligation for your treatment.
• All relevant cards and forms for your insurance will need to be provided to our office in order for the claims to be filed in a timely manner.
• Insurance payments ordinarily are received within 30-60 days from the time of billing. If your insurance company has not made payment to our office within 60 days, we will ask you to pay the balance due at that time. You will be responsible for seeking reimbursement from your insurance company at that time.
• Our office does not guarantee that your insurance company will pay for treatment you receive from our practice. We perform routine insurance billing procedures upon verification of coverage. However, if your claim is denied, you will be responsible for paying the full amount at that time.
• Our office will not enter into a dispute with your insurance company over any claim, although we will provide necessary documentation your insurance company requests to sort out any confusion or questions that may arise. We will cooperate fully with the regulations and requests of your insurance company. It is ultimately your responsibility to resolve any type of dispute over payments made or not made by your insurance company.
The portion of coverage quoted by a dental insurance company is only an estimate, not a guarantee of coverage. Insurance companies will not release the exact amount they will pay for a procedure until the treatment is completed and the claim is submitted. If your insurance company does not allow for assignment of benefits to our dental office, you will be responsible for paying for the treatment in full at the time services are rendered. Alternatively, you may make prior arrangements with our office to pay your estimated portion for treatment provided (estimated expense not covered by insurance) at the time of service, and additionally provide our office with payment in the amount that the insurance company sends to you upon receipt of such payment. You will be responsible for any charges not covered by your insurance company. I have read the above statements and understand that I am financially responsible for any and all charges incurred for services rendered by Pediatric Dentistry of the Ozarks, LLC, regardless of insurance claim status.
Signature of Responsible Party (Parent/Legal Guardian):
Printed Name:
Relationship to Patient: Date:
PERMISSION TO BRING CHILD
Date: In my absence, I hereby give authorization for the person(s) listed below to bring my child(ren) to the office of Pediatric Dentistry of the Ozarks and to consent for any and all recommended dental/medical services. Child’s Name Date of Birth Authorized Person Relationship to
Child
Parent/Legal Guardian Signature: Printed Name: Relationship: This authorization will remain in effect until changes are made by the parent/guardian as signed above. Minor Children (ages 16 and older) My child, may be seen for NAME DATE OF BIRTH
dental attention in the office of Pediatric Dentistry of the Ozarks WITHOUT a
parent/legal guardian present. I understand that I will be contacted for treatment plans
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