Dentistry for Children - New Patient Form

Thank you for choosing our office for your child's dental care. All information in this form is confidential and transmitted over a secure, encrypted connection and will not be sold to any third party. We are fully compliant with all HIPAA Regulations.
Note: The parent or guardian who accompanies the child is responsible for payment at the time of service.

(*) indicates a required field.

1. Tell Us About Your Child

Today's Date *

Child's Full Name *

Nickname

Gender *

Siblings We Treat

Child's Birthdate *

Child's Age

School

Child's Home Number

Social Security Number

Child's Home Address *

Street Address *

Apt #

City *

State *

Zip Code *


2. Who may we thank for referring you to our office?

Name


3. Guardian 1 Information

Name *

Relationship to Child*

Birthdate *

Guardian 1 Home Address *

Street Address *

Apt #

City *

State *

Zip Code *

Employer

Work Number

Home Number *

Cell Number

Social Security Number *

Driver's License Number *

Email Address *


4. Guardian 2 Information

Name

Relationship to Child*

Birthdate

Guardian 2 Home Address

Street Address

Apt #

City

State

Zip Code

Employer

Work Number

Home Number

Cell Number

Social Security Number

Driver's License Number

Email Address


5. Who Is Accompanying Your Child Today?

Name *

Relationship *

Do you have legal custody of this child? *


6. Primary Dental Insurance

Insurance Company Name

Insurance Co. Address

Unit #

City

State

Zip Code

Insurance Co. Phone

Group # (Plan, Local or Policy #)

Policy Owner's Name

Relationship to Patient

Policy Owner's Birthdate

Policy Owner's SSN

Policy Owner's Employer

7. Secondary Dental Insurance

Insurance Company Name

Insurance Co. Address

Unit #

City

State

Zip Code

Insurance Co. Phone

Group # (Plan, Local or Policy #)

Policy Owner's Name

Relationship to Patient

Policy Owner's Birthdate

Policy Owner's SSN

Policy Owner's Employer

8. Signature

The parent or Guardian who accompanies the child is responsible for payment at the time of service.

Our office is commited to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.

I understand that the information I have given is correct 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 the child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.

Signature of Parent or Guardian *
(Please use your mouse or finger on a touchscreen to sign in the box.)

 

Relationship to Patient *

Date *

FINANCIAL AGREEMENT:

As a courtesy to our patients, Dentistry for Children will bill your insurance company. However, the responsibility for payment remains with you. In order for us to bill your insurance you must supply us with complete and current information about your insurance coverage including any necessary forms, identification information, and group numbers. It is the responsibility of the subscriber to know what their eligibility and coverage is with their insurance carrier, as well as if we are contracted with your insurance company. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility. You agree to pay any portion not covered by your insurance.

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Insured dental patients are expected to pay the estimated portion at the time of service. Most dental insurance plans do not cover 100% of the cost of your treatment. Any balance remaining after insurance reimbursement is your responsibility. If insurance has not paid within 60 days of treatment you will need to make full payment to this office and be reimbursed when insurance pays. We mail monthly statements to all our patients with an outstanding balance. Unpaid balances over 45 days will be assessed an annual finance charge of 18%.

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Patients who are not insured are expected to pay in full the day services are rendered. Payments may be made with cash, check, all major credit cards, or Care Credit. If payment cannot be made in full at the time of service then a payment arrangement must be made prior to leaving the office. For uninsured patients we offer a 5% discount of the total balance if paid by cash or check on the day services are rendered. The discount is forfeited if payment is not received in full on the date of service.

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Past due balances- Dentistry for Children makes every attempt to collect past due balances by monthly statements. In addition, we will attempt to contact you via phone and email. All balances are due within 90 days from date of service. After 90 days, all unpaid balances will be turned over to an outside collection agency. Once your account has been turned over to collection services, we will no longer be in a position to provide dental services for your children.

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Change of personal information- It is your responsibility to notify our office of changes in personal information such as insurance, address, phone numbers and email address.

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Divorce- In cases of divorce, please do not place our office in the middle of marital disputes. It is your responsibility to work out payment of your child’s dental care between custodial and non-custodial parent.

Initials


We must emphasize that as providers our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are strictly your responsibility from the date services are rendered.

  • I acknowledge that I am financially responsible for all charges whether or not they are covered by insurance.
  • Checks returned for non-sufficient funds will be charged a $25.00 returned check fee.
  • I also acknowledge that any appointments I fail to show up for are subject to a $25.00 fee.
  • • If it becomes necessary to send your account to collections for any amount owed on this or subsequent visits, the undersigned agrees to pay for all costs and expenses, including reasonable attorney fees.
  • I hereby authorize the doctor to release information necessary to secure the payment of benefits.

Signature of Parent or Guardian *
(Please use your mouse or finger on a touchscreen to sign in the box.)

 

Date *

HIPAA CONSENT

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

  • Conduct, plan, and direct my child’s treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly (i.e., orthodontists or oral surgeons).
  • Obtain payment from your insurance company.
  • Conduct normal healthcare operations such as quality assessments and physician certifications.
  • Remind you of upcoming appointments, treatment options, or alternatives.

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to address below to obtain a current copy of the Notice of Privacy Practices.

Dentistry For Children
651 E. Parkcenter Boulevard, Boise, ID 83706
2320 E. Gala Street, Suite 100, Meridian, ID 83642

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree than you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

Signature of Parent or Guardian *
(Please use your mouse or finger on a touchscreen to sign in the box.)

 

Photography / Videography Policy

We respect the privacy rights of all our patients and our staff. Therefore, we do not allow videography on the premises. Photos solely of your child or children may be permitted in certain circumstances with the approval of the doctor and/or staff member treating your child. It is important for a successful visit that your child can focus on the doctor and/or staff member providing them care. With that in mind, please keep cell phone usage to a minimum in treatment rooms. By signing below, you acknowledge receipt of this policy

Signature * 
   


Signature of Parent or Guardian *
   

Patient Name *

Relationship to Patient *

Date *