Thank you for choosing our office for your child’s dental care. All information in this form are kept confidential.FINANCIAL POLICY(*) indicates a required field.We at Kids Healthy Teeth are committed to providing you with quality care, and we are pleased to discuss our professional fees with you at any time. You are personally responsible for payment at the time of service for all charges that result from care provided by Kids Healthy Teeth, including any amounts not covered by your dental benefit plan. To assist us in establishing your financial account, please:Supply all necessary information for the accurate billing of your claim, including your insurance card, employer information and demographic information.Satisfy all insurance co-payments, deductibles and non-covered services on the day of services are rendered.Provide your insurance company and Kids Healthy Teeth with any additional information requested to complete the processing of claims filed on your behalf.UNACCOMPANIED MINORS: Minors must have an authorization for medical treatment signed by his/her parent/guardian and is responsible for providing current insurance information for self. Please note that co-payments and/or deductibles are expected at the time of service.REGARDING DIVORCE: Kids Healthy Teeth does NOT get involved in disputes between divorced parents regarding financial responsibility for their child’s medical expenses. By signing as guarantor below, you agree to be financially responsible for the care we provide to your child, regardless of whether a divorce decree or other arrangement places that obligation on your former spouse. REGARDING HEALTH PLANS AND INSURANCE: For each visit to Kids Healthy Teeth, it is your responsibility to make sure Kids Healthy Teeth is currently under contract with your managed care plan. Verification of your coverage and benefits may be required. Often this verification requires us to share the reason for your visit with your managed care plan. If we are not contracted with your dental benefits plan, we may require full payment at the time of service. We will supply you with a copy of your itemized statement so that you can file for reimbursement from your dental benefits plan. Should your benefit plan require a more detailed description of services, please have them request it in writing. ASSIGNMENT OF BENEFITS: In consideration of the services rendered or to be rendered by Kids Healthy Teeth, I hereby irrevocably assign, transfer and set over to Kids Healthy Teeth all right, title and interest in all benefits payable for the health care rendered by Kids Healthy Teeth to the patient(s), which benefits are provided in any and all insurance policies, employee benefit plans, re-insurance/stop loss contract and/or third party actions against any other person or entity, for whom my spouse, dependents or I are entitled to recover. I also hereby irrevocably assign, transfer and set over to Kids Healthy Teeth all right, title and interest in any and all claims, administrative appeals and causes of action against all insurance companies, employee benefit plans, re-insurance/stop loss carriers, third party administrators and/or other persons or entities responsible for the payment of health insurance benefits. I authorize my insurer, plan administrator, fiduciary and/or attorney to release to Kids Healthy Teeth any and all insurance policies, plan documents, summary plan descriptions, and/or settlement information upon written request of Kids Healthy Teeth or its attorneys in order to claim such benefits. I authorize payment to be made directly to Kids Healthy Teeth or my treating physician. I understand that there may be professional fees associated with care provided by Kids Healthy Teeth billed separately by the person or organization who provided the services. In consideration of such services, I hereby irrevocably assign, transfer and set over to such persons or organizations all right, title and interest in all benefits payable for the health care rendered by Kids Healthy Teeth to the patient(s), which benefits are provided in any and all insurance policies, employee benefit plans, re-insurance/stop loss contract and/or third party actions against any other person or entity, for whom my spouse, dependents or I are entitled to recovered. RELEASE OF INFORMATION: I agree to the release of any and all medical information, including test results, and financial information necessary to process this and any future claims to my insurer or payer of health benefits, as I may designate that person or entity from time to time, for an indefinite period or until I submit written revocation of this release. This consent to release and obtain information is valid until revoked and I may revoke this consent in writing at any time, except with regard to disclosures already made.As a service to our patients, Kids Healthy Teeth—or a third party with whom Kids Healthy Teeth contracts—provides courtesy appointment reminder calls/text and possibly other important calls regarding financial obligations healthcare related notifications such as recall reminders and treatment reminders, and potentially other texts containing surveys or other marketing or advertising. Such calls or texts may be placed using a prerecorded auto messaging system to the phone number provided to Kids Healthy Teeth. These messages are free service from Kids Healthy Teeth, but your carrier may apply the message and data rates. Opt-in consent is not required to receive services from Kids Healthy Teeth. Your signature on this form confirms your consent to receiving such calls/texts at the telephone number you have provided to us. At any time, you can text STOP to stop receiving text messages.I have read and understand that I am personally responsible for payment on this account.I have read and understand that for any credit or debit card charges over $1,000 a 3.5% processing fee will be assessed.I have read and understand that any balance on my accounts not paid in full by 90 days after the date of service will be sent to collections or small claims court.NO-SHOW/CANCELLATION: Please call at least 24 hours in advance to cancel and/or reschedule appointments for Tuesdays through Fridays, for appointments on Mondays the appointment must be canceled and/or rescheduled by 12 pm the Thursday prior. Appointments NOT canceled in accordance with this policy are subject to a $35 cancellation fee for routine dental services and $100 cancellation fee for dental treatment appointments.Signature of Parent or Legal Guardian(Please use your mouse or finger on a touchscreen to sign in the box.)Signature*Printed Name of Parent/Guardian*Date* Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.