Medical History Form (Page 2 of 2) in pdf

Treatment and Financial Consent

Every effort is being made to keep down the cost of dental care. You can help by making your payment at the time of your visit. You

will be given an estimate of the approximate total fee at the beginning of any necessary treatment and definite financial arrangements will be

made with you at that time.

We request that services rendered on your child’s FIRST visit be paid on the day of the visit. Several methods of payment are available

after that visit which we will be happy to discuss with you. They are as follows:

Payment at time of visit is the customary method.

Mastercard, Visa, or Discover

Insurance – We will file insurance claims as a courtesy to you at no charge. You must provide us with a current insurance

card that shows mailing address and telephone number for benefit determination.

CareCredit - CareCredit is a flexible patient payment program, specifically designed for healthcare expenses, that makes

it easier for you to get the treatment or procedures you want and need. CareCredit lets you begin your treatment or

procedure immediately—then pay for it over time with low monthly payments that are easy to fit into your monthly

budget.

We file dental claims electronically within 24 hours of service. If your insurance company will not accept e-claims, we will file the claim

on a standard insurance claim form. It is your responsibility to provide the office with the correct insurance information.

If benefits are to be assigned to our office, we must have a Dental Insurance Authorization & Release of Information form (see below)

on file that is signed by the insured or responsible party. The office policy regarding payments from your insurance company is that we will file

claims only twice for a specific claim with a grace period of 30 days. If payment is not received within 30 days, a statement will be sent to you

requesting payment in full and suggesting you contact your insurance company.

DENTAL INSURANCE AUTHORIZATION & RELEASE OF INFORMATION

I hereby authorize payment of the group insurance benefits directly to the Dental Office of Pediatric Dentistry of Noblesville otherwise

payable to me. I understand that I am responsible for all costs of dental treatment. I grant the right to the dentist to release my dental/medical

histories and other information about my dental treatment to third party payers and/or other health professionals.

I understand that it is my responsibility to provide the Dental Office with my current insurance information to properly file claims.

If my insurance company has not made payment to the Dental Office within 30 days of the treatment date, I agree to pay the balance

due in full at that time. I understand that interest will be charged on any unpaid amounts more than 60 days past due at an annual percentage

rate of 18%.

X____________________________________________________

Insured or Responsible Party

___________________________________________________

Date

Please remember that you are responsible for payment of all fees to this office. Your dental insurance plan is designed to

share in the cost of your dental treatment. It may not cover the total cost of your treatment. Your insurance policy is a contract

between you and your insurance company. The insurance company has no obligation to our office.

We are happy to cooperate with you and the insurance company in order to help you receive the maximum benefits available under your

policy.

METHOD OF PAYMENT (please check)

CASH_______CREDIT CARD________INSURANCE_______MEDICAID_______CARE CREDIT_______OTHER_______

CONSENT

YOUR CHILD IS A MINOR, THEREFORE IT IS NECESSARY THAT A SIGNED PERMISSION BE OBTAINED FROM A PARENT OR LEGAL

GUARDIAN BEFORE ANY NECESSARY DENTAL SERVICE CAN BE PERFORMED. I GRANT JOE E. FORGEY, D.D.S., CHAD O.

HAZELRIGG, D.D.S. AND CHARLES T. FUHRER III, D.D.S. PERMISSION TO PROVIDE MY CHILD’S DENTAL EXAM AND TREATMENT

AND I WILL BE RESPONSIBLE FOR THE COST OF THE DENTAL CARE. I UNDERSTAND THAT I AM COMPLETELY FINANCIALLY

RESPONSIBLE FOR ALL TREATMENT INCURRED BY THE ABOVE NAMED PATIENT IN THIS OFFICE, INCLUDING ANY AMOUNTS NOT

PAID BY MY INSURANCE COMPANY (IF ANY) WITHIN 30 DAYS OF TREATMENT. I UNDERSTAND INTEREST WILL BE CHARGED ON

ANY UNPAID AMOUNTS MORE THAN 60 DAYS PAST DUE AT AN ANNUAL PERCENTAGE RATE OF 18%. I PROMISE TO PAY ANY

LEGAL INTEREST ON THE BALANCE DUE, TOGETHER WITH ANY COLLECTION COSTS OR ATTORNEY FEES INCURRED TO EFFECT

COLLECTION OF THIS ACCOUNT SHOULD MY ACCOUNT BE TURNED OVER TO A THIRD PARTY.

SIGNED______________________________________________________________________________________

Parent or Guardian

Date

Medical History Form Page 2

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