PERSON RESPONSIBLE FOR ACCOUNT

DENTAL INSURANCE INFORMATION

SECONDARY DENTAL INSURANCE INFORMATION

I acknowledge that I am aware of the Provider’s Notice of Privacy Practices posted at the children’s dental center. The Notice of Privacy Practices describes how identifiable health information may be used and disclosed and states my rights with respect to my medical information.

I understand that the children’s dental center has the right to revise these information practices and to amend the Notice of Privacy Practices. I understand that in the event the Notice is revised, the revision will be posted at the children’s dental center. Upon request, I may obtain a copy of the Privacy Practices Policy.

I can be reached by the following means to discuss issues related to my child(ren’s) dental records, dental appointments, insurance policy and billing:

I hereby give permission for the release of any or all medical and dental information to the person(s) listed below:

The Children’s Dental Center has my permission to use my child(ren’s) photograph publicly to promote the office. I understand that the images may be used in print in office, or on The Children’s Dental Center website and social media accounts. I also understand that no compensation shall become payable to me by reason of such use.

Financial Policy:

Due to increasing changes with insurance benefits, and in effort to maintain communication as our practice grows, we wish to inform you of our financial policy.

• Please let the front staff know of any changes in your dental insurance.
• Fees for service are due at the time of your visit.
• If you have dental insurance, your deductible and co-payment are due at the time of your visit. We will file your insurance claim for you.
• We accept cash, check, VISA, MasterCard, CareCredit

Please note it is the responsibility of our patients to check with the family’s insurance carrier for benefit coverage and to understand their dental insurance policy. If, for any reason, the estimated amount is not paid by your insurance company, it becomes your obligation.

Cancellation/Failure Policy:

the children’s dental center values your time and will do our best to accommodate you and your family’s work/home/school schedules. We use many different methods of appointment confirmation from postcards, phone calls, emails, and text messaging to remind you of your appointment(s) with us. If you cancel an appointment, we ask for a 48-hour notice. If you are unable to give us a two-day notice, we ask that you call as soon as possible to cancel/reschedule your appointment.

Please note: we are unable to cancel or reschedule appointments via email or text.An answering machine is available to take your cancellation after hours.

Failure Policy:

the children’s dental center reserves the right to charge for any failed or missed appointments when patients do not show for their scheduled appointment with no attempt to call our office to cancel or reschedule prior to set appointment.

If multiple appointments are missed in a twelve-month period or a pattern of consistent rescheduling occurs, we may ask the patient to seek dental care elsewhere.

I have read and understand the above policies. I agree to be responsible for the balance due on my family’s account. I also understand The Children’s Dental Center reserves the right to charge for missed/failed appointments.