FINANCIAL POLICY. General Information

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3 FINANCIAL POLICY General Information A parent or legal guardian must accompany each child to the first visit. Once the child is examined, a treatment plan will be formulated with an estimated cost of treatment. However, this treatment plan and estimate is subject to change. The person who brings the child to the office and signs the consent form will be financially responsible for the child s account. Payment is expected on the day that service is rendered. We accept cash, personal checks (but not third party checks), and MasterCard and Visa credit cards. A $25 fee will be assessed on any check returned for insufficient funds. Further appointments will not be scheduled until this fee is paid along with the amount of the returned checks. If for any reason a balance remains unpaid for a period of 45 days, accounts may be transferred to a third party (attorney or collection agency) for payment. All costs incurred by third parties for collection of the unpaid balance will also be due and payable by the responsible party. Patients with Dental Insurance Dental treatment is prescribed based on what is necessary for the optimal dental health of each child. It is not based on dental insurance limitations or coverage. Your dental insurance is a contract between you and your insurance company. Since we are not a party to that contract, we cannot force your company to pay for dental care and we cannot enter into arbitration with them. Therefore, if there is a problem, it is incumbent on you to call your insurance company and attempt to resolve it. As a courtesy to you, we will file your dental claim and allow up to 45 days for payment. However, any and all balances that are 45 days old immediately become your responsibility. Therefore, it is very important that you provide us with accurate information such as subscriber number, address, etc. for claim filing. It is also your responsibility to inform our administrative staff of any changes in your dental insurance coverage. After a treatment plan is developed, you will be given an estimate of what is not covered. Please remember that dental insurance only pays a portion of your bill. Benefits are reduced by deductibles, co-pays, and UCR limitations. We will ask for the estimated portion of what is not covered at each visit. Patients without Dental Insurance After a treatment plan is formulated, the estimated costs will be reviewed with the responsible party. The responsible party is the parent or legal guardian who brings the child to the appointment and signs the consent. Payment is expected at the time service is rendered. If you are unable to pay in full, payment arrangements must be made prior to coming to the office to start treatment. We will consider in house financing arrangements if the total cost of treatment per family is under $400. For those accounts with in house financing, all payments must be made by their due date. We will not provide further treatment (other than true emergency treatment) until a delinquent account is brought current. In addition, if any installment becomes 45 days past due, KidzSmile Dentistry may without notice demand, declare all unpaid installments, attorney s fees, interest and late fees immediately due and payable. If this occurs, accounts may be transferred to a third party (attorney or collection agency) for payment. Signature of Parent/Legal Guardian

4 CONSENT FOR SERVICES I have reviewed this questionnaire and answered its questions accurately, to the best of my knowledge. I understand that the answers I have provided will be used by the dentist to determine appropriate dental treatment for my child. I agree to notify the dentist if any change in my child s health status should occur. I acknowledge that by presenting my dependent for dental treatment today or on any future occasion at the office of KidzSmile Dentistry, I give consent for treatment. The staff at KidzSmile Dentistry has fully explained the procedure(s) and risks to my satisfaction. Furthermore, any questions have been answered. If I wish to withdraw my consent, I will request that the treatment be discontinued, prior to my child being taken to the operatory for treatment. As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. One of our staff members in the business office will be glad to assist you with financial arrangements when necessary. Our payment options are as follows: Cash, Checks, MasterCard or Visa. Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient s insurance forms, assist in making collections from insurance companies, and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. All services are due and payable on the date they are initiated. If for any reason a balance remains unpaid for a period of 45 days, accounts may be transferred to a third party (attorney or collection agency) for payment. All costs incurred by third parties for collection of the unpaid balance will also be due and payable by the responsible party. In consideration for the professional services rendered to my child, I agree to pay for said services to the Doctor or their assignee at the time services are rendered. I further agree that I will pay KidzSmile Dentistry in the time frame agreed upon. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit were instituted hereunder. I grant my permission to you or your assignee to telephone me at home or at my work to discuss matters related to this form. I have read the above conditions of treatment and payment and agree to their content. Signature of Parent or Legal Guardian Relationship to Child

5 CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION & NOTICE OF PRIVACY PRACTICES SECTION A: PATIENT/GUARDIAN GIVING CONSENT Name: Address: Telephone: Patient Name: SECTION B: TO THE PATIENT/GUARDIAN PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the address listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation and that we may decline to treat or to continue treating your child if you revoke this Consent. SIGNATURE I, have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations. Signature of Parent/Legal Guardian YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign. Communication barriers prohibited obtaining the acknowledgement

6 Permission to Authorize Treatment I give permission for the below listed person(s) to bring my child/children in for dental treatment. I understand that I have received and accepted any treatment plans and have signed financial papers. Furthermore, my signing and allowing another person to bring my child to their dental appointments, I understand that I am responsible for all co-pays, payments and balances. **************************************************************************************************************************************************************** **************************************************************************************************************************************************************** Behavior Management Children s dentistry can be more challenging than other disciplines of dentistry. Our goal is to provide the highest quality of care in the safest manner to every child. A child s anxiety is manifested by extreme bodily movements such as kicking, pinching, grabbing sharp instruments, jerking the head, temper tantrums, etc. It is a common practice in dentistry to employ a variety of methods to help protect your child. Below is a brief discussion of these methods. Bite Block/Mouth Prop/Tooth Stool: A device that allows your child to keep his/her mouth open for extended periods of time so that we can complete exams or restorative treatment. It also protects your child from biting on a sharp instrument and from us being accidentally bitten. OUCH! Hand/Wrist Holding: Young children have a tendency to grab during the dental visit. If we are working with sharp instruments, drills, etc., we may hold your child s hands to prevent grabbing that could lead to injury. Papoose Board/Pedi Wrap: These are body wraps commonly used in emergency rooms as well as children s dental offices. If a child is kicking or moving in such a way that it becomes dangerous to complete treatment, we may use a wrap to help stabilize a child. The primary purpose of this method is to allow treatment to be completed safely and expediently. I have read the above information and understand the need to use the described methods so that my child can be treated safely. I give permission to KidzSmile Dentistry to use Behavior Management if that is what is best in their professional judgment. I further understand that if I choose not to give permission, treatment might not be completed for my child. Patient s Name: Signature of Parent/Legal Guardian