Child Patient Information

Date Today

SS / HIC / Patient ID No.

Date of Birth

Name of Minor / Child

First Name

M.I.

Age

Nickname

Hobbies

Cell Phone No.

Home Address

City

State

Zip

Mailing Address

City

State

Zip

School Name

School Phone No.

Person financially responsible

Home Phone No.

Work Phone No.

Who may we thank for referring you?

INSURANCE

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Child Medical Assistant I.D. No.

DENTAL HISTORY

Date of last visit to a dentist

For what service?

Minor /Child's Physician

City / State

Phone No.

Date of last physical examination

Results

Medication

Allergies

EMERGENCY CONTACT

In the event of an emergency, whom should we contact?

Add Additional Contacts

AUTHORIZATIONS

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if my minor child ever has a change in health.

Minor / Child / Consent

I am the parent, guardian, or personal representative

and there are no court orders now in effect that prohibit me from signing this consent. I do hereby request and authorize the dental staff to perform necessary dental services for the child named above, including but not limited to x-rays, and administration of anesthetics, which are deemed advisable by the doctor, whether or not I am present when the treatment is rendered.

Insurance Assignment and Release

I certify that my dependent(s) is covered by insurance with

and assign directly to Dr.

all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named doctor may use my minor/child's health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when the current treatment plan is completed or one year from the date signed below.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Parent, Guardian or Personal Representative

Relationship to Patient

Date

Office Policies / Dental Insurance / Private Pay

We are committed to providing you with the best possible care that's why we always try to present you with the best dental solution possible to treat your personal situation. Here are some important things you should know about receiving care at our office.

Time is reserved especially for you and we strongly encourage all patients to keep their appointments. We require at least 48 hours notice to avoid a $50/hour cancellation fee (emergencies are an exception.) . $100.00 fee is charged for a missed Saturday appointment.

Balances older than 60 days will be subject to a monthly $25.00 late fee until the account is brought current.

Dr. Gniadek does require payment in full, including deductible and co-payment, at the time your services are rendered unless payment arrangements have been approved in advance by our staff. We accept Cash, Check, MasterCard, Visa, Discover, American Express and Care Credit.

Once treatment has begun and then is cancelled by the patient, Dr. Gniadek reserves the right to retain a minimum of $100 of the charged fee to cover any time and materials lost.

Your dental benefits are a contract between your employer and an insurance company. If you have any questions regarding your dental benefits, please contact your employer and/or insurance company directly.

We currently accept all private care insurance plans, however, we may or may not be an in-network provider for your insurance. It is YOUR responsibility to check if Dr. Gniadek is in your network upon your appointment. Although we maintain computerized histories of payment by a given company, they do change. Therefore, it is the most up-to-date information we have but it is ONLY AN ESTIMATE (if you would like to know your insurance benefit, we will be happy to file a "pre-treatment authorization") with your insurance company prior to treatment. Keep in mind this is not a guarantee of coverage, it does delay treatment, but will give you a better idea of out-of-pocket expenses).

We bill your insurance company as a courtesy. If insurance does not pay within 90 days, Dr. Gniadek reserves the right to request payment in full for services from you. You can collect the insurance funds that are due you. This is rare, but it is important that you recognize that the insurance you have is a legal contract between YOU and your insurance company. Our office is not and cannot be a part of that legal contract. Ultimately you are responsible for all charges incurred in our office.

In the event of a walk-in emergency during regular business hours, a $70.00 emergency fee will be charged in addition to the necessary treatment fees. Established patients will be charged a $150.00 emergency fee for after hour emergencies in additional to the necessary treatment fees.

If needed there will be a $50.00 fee for a complete copy of your dental records.

Situations of Divorce

Divorced parents bringing a child to an appointment are solely responsible for all fees incurred during each visit. Parents will not be billed separately. By initialing, you agree to pay all costs of collection. (if necessary) including, but not limited to, reasonable attorney's fee.

I acknowledgement I have read and understand all the above conditions.

Signature / Name

Date

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

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 treatment and follow-up among the multiple healthcare providers who may be involved in my treatment directly and indirectly.
Obtain payment from third-party-payers.
Conduct normal healthcare operation such as quality assessments and physician certifications.

I have received, read , and understand your Notice of Privacy Practices containing a more complete describe of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices.

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

Formatted text

Patient Name / Signature

Relationship to patient

Date

Please list names of persons who can release your information to:

Request for Confidential communications

Name of Patient

Date of Birth

Address

Home No.

Work No.

Cell No.

Email address

I do NOT want a reminder left at all

I do NOT want a postcard sent

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

I understand that I will in cur a missed appointment fee should. I fail to keep my appointment (without 24hr notification).

Your information will be encrypted.