Patient Information for a Minor Patient
Responsible Party Information
(Person accompanying child to most appointments, making treatment decisions, and is financially responsible)
Other Guardian Information
(Other parent or step-parent, insurance subscriber, or person occasionally accompanying patient to appointments)
Emergency Contact: Phone: Relationship:
Dental Benefit Plan Information
Photograph / Media Authorization
I hereby give my consent for Dr. Allen Job and All Smiles Pediatric Dentistry to take photographs, slides and/or video of my child(ren). I also grant permission to reproduce, print and/or publish these images for use in social and internet media, marketing, advertising, articles, and lectures.
I do not expect compensation, financial or otherwise, for the use of these images.
Please initial ONLY ONE:
||I consent to the use of my photographs, slides, and/or video for articles, lectures, marketing, advertising, and social media.
||I consent to the use of my photographs, slides, and/or video ONLY for office use.
||I DO NOT consent to the use of my photographs, slides, and/or video.
I understand that the information disclosed under this authorization may be subject to re-disclosure and no longer protected by the federal privacy regulations. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, enrollment, or eligibility for benefits. Finally, I understand that I may revoke this authorization in writing at any time by sending a letter to my dental care provider stating my revocation and the effective date, except to the extent that action has been taken in reliance on this authorization.
Financial and Office Policy
Thank-you for joining our Practice! We are committed to providing you and your child with the best possible care. Toward this goal, we would like to explain your financial and scheduling responsibilities with our practice.
Office Surveillance Acknowledgment: I acknowledge that video surveillance is conducted on the premises of All Smiles Pediatric Dentistry. I understand that this video surveillance is conducted in all dental treatment areas, business areas, and children’s play areas only at present. All Smiles Pediatric Dentistry retains ownership of video surveillance records as permanent records and does not include transfer of this video recording when transferring dental records to any other medical or dental provider, insurance company, or to parent/legal guardian. This video surveillance may be viewed and monitored at any time by authorized persons for the purpose of staff training, verification of compliance with employment policies of All Smiles Pediatric Dentistry, for purposes of legal proceedings, or to investigate misconduct.
Payment: Payment is due at the time services are rendered. We accept the following forms of payment: Cash, Master Card, Visa, Discover, and checks. Financial arrangements are discussed during the initial visit and a financial agreement is completed in advance of performing any treatment with our practice when necessary.
Insufficient Funds Fee: A $25.00 returned check service charge for the first returned check, and a $35.00 charge for each subsequent returned check by the same payer will be assessed as well as any treble damages.
Dental Benefit Plans: Your dental benefit is a contract between you, or your employer, and the dental plan. Benefits and payments received are based on the terms of the contract negotiated. We are happy to help our patients with dental benefit plans to understand their coverage.
If we are a contracted provider with your plan, you are responsible only for your portion of the approved fee as determined by your plan. We are required to collect the patient’s portion (deductible, co-insurance, co-pay, or any amount not covered by the dental benefit plan) in full at time of service. If our estimate of your portion is less than the amount determined by your plan, the amount billed to you will be adjusted to reflect this, and you will be responsible for the difference. All Smiles Pediatric Dentistry, Allen Job, DDS is a contracted provider for MetLife, Delta Dental, Guardian, Cigna, and Principal.
If we are not a contracted provider with your dental benefit plan, it is the insured’s responsibility to verify with the plan whether the plan allows patients to receive reimbursement for services from out-of-network providers. IF your plan allows, reimbursement for services, our practice can file the claim with your plan and receive reimbursement directly from the plan if you “assign benefits” to us. In this circumstance you are responsible, and will be billed for any unpaid balance for services rendered upon receipt of payment from the plan, even if that amount is different than our estimated patient portion of the bill. IF you choose not to “assign benefits” to our practice, you are responsible for filing the claim and obtaining reimbursement, and will be responsible for payment to our practice before, or at the time of service.
Scheduling appointments: We reserve time in our schedule for each patient procedure so when a patient cancels an appointment, it impacts the number of patients we are able to care for each day. To maintain the utmost service for all our patients, we do require 24-hours’ notice to cancel or reschedule an appointment. With less than 24-hour notice, a fee of $50.00 may be required. We do understand emergencies arise, and ask that you notify us as soon as possible.
Print Responsible Party Name:
Signature of Responsible Party (Use mouse, stylus or finger to sign):