Office Policies

Child's Name: (Last Name, First Name)

Sex: Male Female

Date of Birth:

Age:

Child's Name: (Last Name, First Name)

Sex: Male Female

Date of Birth:

Age:

Child's Name: (Last Name, First Name)

Sex: Male Female

Date of Birth:

Age:

Child's Name: (Last Name, First Name)

Sex: Male Female

Date of Birth:

Age:

Child's Name: (Last Name, First Name)

Sex: Male Female

Date of Birth:

Age:

General Office Policies

As a courtesy, our office pre-determines your family’s individual insurance coverage. Estimating individual coverages allows us to collect only the patient portion for dental services. For your convenience, Growing Grins Pediatric Dentistry will submit insurance claims on your behalf. To take advantage of this service, we require complete insurance information at time services are rendered. We allow a 30 day grace period for insurance to pay on the claim. Insurance balances past 30 days become the responsibility of the financially responsible party. A statement will be issued immediately after payment has been issued to Growing Grins Pediatric Dentistry from your insurance company.

Payment is due at the time services are rendered. We accept cash, check, Mastercard, Visa, American Express and CareCredit.The parent or guardian accompanying the child to the appointment is considered the financially responsible party. A statement will be issued with your balance and will be considered past due if not paid by the date noted. We reserve the right to assess a $10.00 late fee on accounts considered delinquent. Accounts that are within sixty (60) days may be referred to an outside collection agency. Recuperation of expenses incurred in the collection process will be the financially responsible party’s responsibility.

I request that payment of authorized dental or any other applicable health insurance benefits be made on behalf to Growing Grins Pediatric Dentistry for any services provided to my dependent(s). I authorize any holder of dental/medical information about my dependent(s) to release any information needed to determine benefits or benefits payable for related services to the applicable insurance agencies.

In order to be respectful of the doctors’ and all patients’ time, kindly give sufficient notice if you are unable to keep your appointment. If appointments are rescheduled without 48 hours notice you may be charged a fee. If you miss three appointments without prior timely notice you may be discharged from the practice. If more than 10 minutes late we may ask you to reschedule.

A copy of the Notice of Privacy Practices for Growing Grins Pediatric Dentistry is available to you. Please ask the receptionist when you arrive if you would like a personal copy. This notice describes how Growing Grins Pediatric Dentistry may use and disclose your child(ren)’s protected health information, certain restrictions on the use and disclosure of their health care information and rights you may have regarding your child’s protected health information.

Parent/Guardian Name:

Relationship:

Date:

Insurance Information

If you expect insurance to pay for services, please make sure to present the insurance card at your child(ren)'s appointment.

Primary Coverage

Subscriber name (Last/First):

Date of birth:

SSN:

Relationship to patient:

Insurance company name:

Insurance phone number:

Group number:

Employer:

Secondary Coverage

Subscriber name (Last/First):

Date of birth:

SSN:

Relationship to patient:

Insurance company name:

Insurance phone number:

Group number:

Employer:

Responsible Party Information

*The parent or guardian that signs this paperwork is the responsible party of guarantor of the financial account. This may be different than the insurance subscriber.

Name (Last/First):

Sex: Male Female

Date of Birth:

Age:

SSN:

Address:
(Address/City/State/Zip)

Home phone:

Cell phone:

Email address:

Employer:

Employer address:

Employer phone:

Guarantor signature

Please use your mouse, stylus, or finger to sign your name in this box.

Other persons authorized by guarantor to have access to HIPAA protected information:

Name (Last/First):

Relationship to patient:

Phone:

Name (Last/First):

Relationship to patient:

Phone:

Referral Information

Please share with us how you heard about our office:

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