Talia Pike DMD Patient Information
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1 Talia Pike DMD Patient Information Patient Name Nickname Birthdate Age Sex Address Apt/Suite# City State Zip Home # School/Grade Parent Name Birthdate Employer SSN: Work # Cell # Address Parent Name Birthdate Employer SSN: Work # Cell # Address How did you hear about our office? Is it ok to leave messages regarding confirming appointments, insurance questions, etc? What is the reason for your child s visit today? Dental Insurance Information (please fill out ONLY if insurance card not present) Primary Policy Holder Name Birthdate SSN# Employer s Name & Address Insurance Name & Address ID # Group # I authorize my insurance to pay directly to Dr. Pike if my insurance plan is taken by Dr. Pike. If I am covered by any other plan, I will pay in full when services are rendered. I understand that all insurance policies are different and I am responsible for knowing my plan provisions. I understand I will be responsible for all co-payments, deductibles and any charges that are denied by my insurance plan. Signature of Parent/Guardian: Date: 1
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4 Consent for Dental Treatment I request and authorize Dr. Pike and her staff to examine and provide my child with comprehensive dental treatment including, but not limited to cleanings, fillings, crowns, extractions, and nitrous oxide, if required. I further request and authorize the taking of dental x-rays as may be considered necessary by Dr. Pike to diagnose and/or treat my child s dental condition. I understand that I will be responsible for any charges incurred on this child for dental treatment. I will allow photographs to be taken of my child and/or my child s teeth for diagnostic or educational purposes. I understand that dental treatment for children includes efforts to guide their behavior by helping them to understand the treatment in terms appropriate for their age. Dr. Pike will provide an environment likely to help children learn to cooperate during treatment by using praise, explanation and demonstration of procedures and instruments, and using variable voice tone. Signature of Parent/Guardian: Date: Non-Guardian Consent I give my permission for the following person(s) to accompany my child to his/her dental visits. All person(s) listed below must be over the age of 18. This includes making decisions regarding treatment that may arise during the scheduled appointment. This also gives Dr. Pike and her staff permission to discuss treatment and conditions with the person(s) listed below. I understand that I am responsible for payment at the time of services and should someone accompany my child other than myself, arrangements for payment must be made before the scheduled appointment time. Name Relationship to child Signature of Parent/Guardian: Date: 4
5 Financial Policy Please understand that financial arrangements are made directly with you. For your convenience, the following outlines our financial policies: 1. Payment is due in full for each appointment as services are rendered and is to be paid by the person accompanying the child. We accept cash, MasterCard, Visa, Discover and Care Credit. You will be responsible for payment of all costs and fees incurred, including attorney's fees, should collection efforts be made in order to fulfill a debt. 2. Dental Insurance: Please check with our staff to make sure that we accept your child s insurance plan. For all insurances that we do not accept, we will be happy to submit a claim to your insurance electronically, however payment is due in full at time of service. The type of plan chosen by you and/or your employer determines your insurance benefits. As such, we have no control over the terms of your contract, the method of reimbursement or the determination of your insurance benefits. Any reimbursements by your insurance company other than those we directly participate with should be made directly to you according to the terms of your contract with them. 3. Pre-treatment Authorization: Some insurance companies recommend an estimate of the work to be done and the fees to be charged before determining their benefits to you. If so, we will provide you with the pre-treatment fee estimate. In this case, it will be up to you to determine if you wish to proceed with the treatment before the insurance benefit is determined. 4. Fillings: Our dental material of choice is a white (composite resin) filling. Please be aware that your insurance company may not pay for a resin filling at the same level as a silver (amalgam) filling. The co-payment is your responsibility. In some cases, Dr. Pike may recommend placing a silver crown instead of a resin filling. 5. Nitrous Oxide / Analgesia: Our office uses Nitrous Oxide Analgesia (Laughing Gas) for the comfort of our young patients. This fee is not always covered by dental insurance. We thank you for your payment on the date of service. 6. Appliances: The entire cost of the appliance must be paid on the day your child s impressions are taken. This is necessary because our office must pay the laboratory bills when appliances are ordered, not when they are completed. 7. Emergency Treatment: All emergency treatment must be paid in full at the time the service is rendered. Please remember, even if you have insurance coverage, you are responsible for payment of your account. Understand that your insurance coverage is a relationship between you, the insured patient and your insurance company. Your understanding and cooperation with this matter is greatly appreciated. Past due accounts are subject to a monthly service charge and will be turned over for collection by an outside agency.if your account is turned over to a collection agency, all court costs and attorney fees will be applied. I have read and understand my obligation. Signature of Parent/Guardian: Date: 5
6 Notice of Privacy Practices-HIPAA I had the opportunity to read over the HIPAA guidelines and ask any questions that I had regarding HIPAA. Signature of Parent/Guardian: Date: Office Policies The office attempts to schedule appointments at your convenience and when time is available. If your child is under the age of 5, we recommend that you schedule a morning appointment for your child. Younger children are more cooperative when they are well rested. Since appointed times are reserved exclusively for each child, we ask that you please notify our office 24 business hours in advance of your scheduled appointment time if you are unable to keep your appointment. We realize that unexpected things can occur, but we ask for your assistance in this regard. If your child misses an appointment without notifying us 24 business hours in advance, a cancellation fee will be applied to your account. This fee will vary depending on the length of time reserved for your child. We try our best to accommodate our patients, so please be courteous and let us know if you cannot make it to your child s scheduled appointment. As a courtesy, our office calls to confirm all scheduled appointments. We kindly ask that only 1 (one) parent &/or guardian accompanies the child in the treatment room for any dental treatment needed (ex. fillings, extractions etc.). Siblings are not permitted to sit on their parent s lap. I have read and understand the Office Policies and agree to abide by its contents: Signature of Parent/Guardian: Date: 6
7 Consent for Attempted Treatment To all patients where treatment is attempted, but not completed due to lack of cooperation or other unforeseen circumstances, a fee based upon time and materials used will be charged (ex. chair time, nitrous oxide, local anesthesia). Please understand that time was set aside for your child in order for treatment to be performed. If your child is uncooperative, we reserve the right to charge for our time and materials used/opened. Thank you for understanding! Attempt Treatment (DATTX) $50.00 Nitrous Oxide (D9230) $60.00 Anesthesia (D9215) $25.00 Non-Intravenous Conscious Sedation (D9248) $25.00 Temporary Filling (in case treatment is started, but cannot be completed) (D2940) $85.00 *Please note: if the patient has insurance, the temporary filling (D2940) will be billed out. Co-insurance deductible and co-pay will apply. In some instances, nitrous oxide (D9230) may also be covered. Signature of Parent/Guardian: Date: Confirmation of Appointments We have an automated system that confirms appointments by and text. If the appointment is not confirmed, the office will also attempt to call you to confirm the appointment. TEXT Best number to text: PHONE CALL Best number to call: Updated address (if moved): 7
Talia Pike DMD Patient Information
Talia Pike DMD Patient Information Patient Name Nickname Birthdate Age Sex Address Apt/Suite# City State Zip Home # School/Grade Parent Name Birthdate Employer SSN: Work # Cell # Email Address Parent Name
Permission Letter. Patient Name(s):
Permission Letter Patient Name(s): If someone other than the parent or legal guardian may bring your child (ren), please list their name(s) below. They must be 18 years of age and have a photo i.d. We
PATIENT INFORMATION. Parent/Legal Guardian #1: Name: Date of Birth: / / Occupation/Employer: SS#: Work phone: Mobile: Home: address:
! PATIENT INFORMATION Your Child s Name: Nickname: Date of Birth: / / Age: Identifies Male: Female: School: Grade: Child s primary address: City: Zip: Telephone: Parent/Legal Guardian #1: Name: Date of
FILING- THE PATIENT IS ULTIMATELY RESPONSIBLE FOR PAYMENT IN FULL OF THEIR ACCOUNT, NOT THE INSURANCE COMPANY.
FINANCIAL AGREEMENT- PAYMENT IS REQUIRED FOR ALL DENTAL SERVICES AT THE TIME TREATMENT IS RENDERED. We accept Visa, MasterCard, Discover, American Express, Care Credit, Cash or Check. INSURANCE FILING-
NAME: LAST FIRST MI SEX: M F BIRTH DATE: / / AGE: SS# - - STATE ZIP HOME PHONE CELL. How did you hear about our office? STATE ZIP HOME PHONE WORK
PATIENT INFORMATION NAME: LAST FIRST MI SEX: M F BIRTH DATE: / / AGE: SS# - - ADDRESS CITY STATE ZIP HOME PHONE CELL OTHER EMAIL How did you hear about our office? HEAD OF HOUSEHOLD NAME: LAST FIRST MI
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES 2013 Murphy Dental 608 East Harmony Road, Suite 301 Fort Collins, CO 80525
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES 2013 Notice to Patient: We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose
Permission to Discuss Medical Information HIPPA PATIENT ACKNOWLEDMENT. Patient Name:
Patient Name: HIPPA PATIENT ACKNOWLEDMENT (Must be filled out by a parent/guardian if the patient is under the age of 18) We are required by law to maintain the privacy of protected health information
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