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Payment or Co-Payment is to be paid in full at each appointment. We accept the following methods of payment: Cash Money Order, American Express, VIsa, Mastercard, Discover Card, CareCredit, & Personal Checks. Driver's License No. or State ID No. is required to accept payments. I AUTHORIZE all forms of communication with the information I provided to NMPD and its third party affiliates. I authorize the dental staff to perform the necessary dental services my child may need. I authorize the dentist to release all information necessary to secure payment. I authorize my insurance company if being billed by the office to opay directly to the dentist or dental group insurance benefits otherwise payable to me. I authorize the use of this signature on all insurance submission. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on behalf of my dependents.
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.
Payment Options Include:
Must be present to sign with two forms of identification
Thank you for choosing Northern Michigan Pediatric Dentistry, P.C. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable as possible by offering several payment options.
Please Note
Northern Michigan Pediatric Dentistry, P.C. requires estimated co-payment AT TIME OF SERVICE. A $10.00 Delay of Payment Fee will apply to the account if any balance is NOT paid at the time of service. Three times (3x) without paying at time of service will be a dismissal from the practice. As a courtesy, we do file a Pre-Determination for treatment to your dental insurance to get the estimated insurance portion for you. It becomes the patient’s (parent/guardians) responsibility to cover procedures that are not covered by their insurance plan including ALL limitation policies. Not all services are covered by your insurance carrier and every insurance plan has its own unique “quirks” & exceptions. As a policy holder, it is YOUR responsibility to know your plan AND know and watch your plan limitations. WE ONLY USE COMPOSITE (WHITE) FILLINGS IN OUR OFFICE. You will incur an out-of-pocket expense if your insurance company reimburses at an amalgam (silver) filling rate. Contact your insurance carrier with any questions regarding your plan’s benefit and limitations
For patients with dental insurance that we bill, we are happy to work with your carrier to maximize your benefit and as a courtesy, we will directly bill them for reimbursement for your treatment. However, if we do not receive payment from your insurance carrier w/in 30 days, you will be responsible for payment of your treatment fees and possibly getting a collection of your benefits directly from your insurance carrier. If the account is not paid in full by 60 days from the date of service, texts, email if available, a letter, and/or possibly a call will be made before collection/court proceedings begin. A Billing Charge of $5.00 will apply to ALL statements that are sent. In the event of collection action, the debtor agrees to pay all collection cost 28%, including reasonable attorney fees or additional costs associated with efforts of collecting or obtaining this debt. As an office policy, we do require a Social Security Number (SSN) for ALL policyholders AND guarantors (Responsible Parties). The responsible party is determined by who brings the child to the first visit & signs forms. A copy of their ID will be required. NMPD is ONLY IN NETWORK with Delta Dental Premier plans and the Careington Platinum network. We participate in some BCBSM plans and some Delta PPO plans. This is dependent on your individual plan. We do bill to other insurance companies but they will be out of network & you will be responsible for anything your insurance does NOT cover.
You agree, in order for us to service our account or to collect any amount you may owe, NMPD and associated 3rd parties of NMPD may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or e-mails, using any e-mail address you provided to us. Methods of contact may include using pre-recorded/artificial voice messages and/or the use of an automatic dialing device, as applicable. You DO specifically consent to receive telephone calls, short messages services, text messages, or other messages made or delivered to the telephone numbers that were provided. That you acknowledge that these calls may be made or delivered using an automatic dialing system and/or an artificial or pre-recorded voice, made by the Center or its business associates for purposes of treatment, payment, and health care operations.
We are NOT responsible nor do we follow any parental agreements of percentage/or other party co-pays in separated families unless a copy of a court-documented divorce decree is provided stating the office must take those percentages. It is a responsibility and an expectation that all balances will be paid at the time of service by whoever brings them or if not paid then ultimately by the responsible party of said balance and if additional monies are needed. Any balances will default to the guarantor on the account.
No appointments will be made if there is a balance on the account for the patient or any members of their family. We are unable to accept post-dated checks. Northern Michigan Pediatric Dentistry, P.C. charges $35.00 for returned checks. You may no longer be able to use this form of payment for future visits.
**If you have any questions, please do not hesitate to ask and we will do our best to help.
IN THE EVENT OF AN EMERGENCY, WHO SHOULD WE CONTACT?
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I have reviewed this questionnaire and answered its questions accurately, to the best of my knowledge. I understand that the answers I have provided will be used by the dentist to determine appropriate dental treatment for my child, and I agree to notify the dentist if any change in my child's health status should occur. I authorize the dental staff to perform the necessary dental services my child may need.
PAYMENT OR CO-PAYMENT IS DUE IN FULL AT THE TIME OF TREATMENT, UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE.
1241 E 8th Street / Traverse City, MI 49686 / (231) 947-4566
IMPORTANT: Please understand, a parent or legal guardian must accompany the patient to the first appointments. Your child’s first appointment will consist of a New Patient exam and consultation. Our office will schedule any treatment after this exam. Please bring this completed packet of paperwork, current dental insurance card, and driver’s license. If you are more than 10 minutes late, or do not have the paperwork completed, your appointment may be cancelled.
There are many times that our patients require urgent or emergency treatment and therefore require an appointment as soon as possible. When patients give the office advance notice of their need to cancel a scheduled appointment, this time can then in turn be allocated to these patients in urgent need of treatment. In this way the office can best serve the needs of ALL patients
We at Northern Michigan Pediatric Dentistry welcome you to our "family"! We look forward to taking care of your child's oral health needs.
Payment Options include:
¹If paid within the promotional period. Otherwise, interest assessed from purchase date. Minimum monthly payment required. ²Subject to credit approval
Northern Michigan Pediatric Dentistry, P.C. requires estimated co-payment AT TIME OF SERVICE. A $10.00 Delay of Payment Fee will apply to the account if any balance is not paid at the time of service. As a courtesy, we file a Pre-Determination for treatment to your dental insurance to get the estimated insurance portion for you. It becomes the patient’s (parent/guardians) responsibility to cover procedures that are not covered by their insurance plan including ALL limitation policies. Not all services are covered by your insurance carrier and every insurance plan has its own unique “quirks” and exceptions. As a policy holder, it is YOUR responsibility to know your plan AND know and watch your plan limitations. WE ONLY USE COMPOSITE (WHITE) FILLINGS IN OUR OFFICE. You will incur an out of pocket expense if your insurance company reimburses at an amalgam (silver) filling rate. Contact your insurance carrier with any questions regarding your plan’s benefit and limitations.
For patients with dental insurance (with the exception of Medicaid, Crippled Children’s Fund, and CSHCS) we are happy to work with your carrier to maximize your benefit and as a courtesy we will directly bill them for reimbursement for your treatment. However, if we do not receive payment from your insurance carrier within 30 days, you will be responsible for payment of your treatment fees and possibly getting collection of your benefits directly from your insurance carrier. If the account is not paid in full by 60 days, a letter and call(s) will be made before collection/court proceedings begins. A Billing Charge of $5.00 will apply to ALL statements that are sent. In the event of collection action, debtor agrees to pay all collection cost 28%, including reasonable attorney fees or additional costs associated in efforts of collecting or obtaining this debt. As an office policy, we do require a Social Security Number (SSN) for ALL policy holders AND guarantors (Responsible Party).
You agree, in order for us to service our account or to collect any amount you may owe, NMPD and associated 3rd parties of NMPD such as collection agencies may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. It is possible for others to see this information if they have access to those devices. We may also contact you by sending text messages or e-mails, using any e-mail address you provided to us. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable. You DO specifically consent to receive telephone calls, short messages services, text messages, or other messages made or delivered to the telephone numbers that were provided. That you acknowledge that these calls may be made or delivered using an automatic dialing system and/or an artificial or pre-recorded voice, made by the Center or its business associates for purposes of treatment, payment, and health care operations.
We are NOT responsible nor do we follow any parental agreements of percentage/or other party co-pays in separated families unless a copy of a court documented divorce decree is provided stating the office must take those percentages. It is a responsibility and an expectation that all balances will be paid at time of service by whomever brings them or by responsible party if additional monies are needed. Any balances will default to the guarantor on the account.
If you choose to discontinue care before treatment is complete, you will receive a refund if needed less the cost of care provided. All refunds, with the exception of Care Credit, are given by check from the Doctor. No appointments will be made if there is a balance on the account for patient or any members of their family.
We are unable to accept post dated checks. Northern Michigan Pediatric Dentistry, P.C. charges $35.00 for returned checks. You may no longer be able to use this form of payment for future visits. **If you have any questions, please do not hesitate to ask and we will do our best to help.
I authorize the person(s) listed below, in addition to the parent / legal guardians to take my child to the above-named providers for treatment. I authorize the administration of measures as are deemed necessary for those appointments.
I hereby give permission to consent and authorize the names below to act on my behalf. I give them my permission to bring my child, to discuss, and to make dental decisions in all matters of the child. This includes but is not limited to making appointments, discussion of financial information, and authorizing of any form of treatment.
By listing the adults below, I authorize the staff of Northern Michigan Pediatric Dentistry to disclose any protected health information as needed to facilitate the dental care of my child. If you do not want anyone else to bring your child please write “none” and sign and date the bottom. This is active and current until I provide information in writing stating otherwise.
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You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims
PLEASE LIST ANY OTHER PARTIES WHO ARE ACTIVELY INVOLVED IN YOUR HEALTH CARE AND WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION: (This includes step parents, grandparents and any care takers who can have access to this patient’s records):
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In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third-party remuneration from these affiliated companies. We, under the current HIPAA OmnibusRule, provide you with this information with your knowledge and consent.
The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTORS / FACILITIES IN THE FUTURE.
OFFICE USE ONLY
As Privacy Officer, I attempted to obtain the patient’s (or representatives) signature on this Acknowledgement but did not because:
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003, and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain; including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:
Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide you
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of health professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities.
Michigan Dental Patient Consent Law: We are required by Michigan Law to obtain your written consent prior to making certain disclosures of your health information.
Your authorization: In addition to our use of your health information for treatment, payment, or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.
To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable interferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information
Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.
Required by Law: We may use or disclose your health information when we are required to do so by law
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).
PATIENT RIGHT
Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practically do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $2.00 for each page, $20.00 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure).
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations, and certain other activities, for the last 5 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restriction: You have the right to request that we place additional restricts on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. {You must make your request in writing}. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request
Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.
Electronic Notice: If you receive this Notice on our Website or by electronic mail (E-mail), you are entitled to receive this Notice in written form.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices, or have questions or concerns, please contact us.
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to use using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.
We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
Contact Officer: Dr. Matthew Mandeville Phone: 231-947-4566 Fax: 231-947-9873
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