Mountain Kids Pediatric Dentistry Patient Information Page 2
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2Mountain Kids Pediatric Dentistry
CONSENTS
Welcome to Mountain Kids Pediatric Dentistry. Please take a few minutes to review the following financial agreement and Receipt of
Notice of Privacy Practices. We hope you understand that our credit and collection policies are a necessary part of assuring the
financial resources needed to maintain this office for our patients and the community. Please initial each paragraph.
____________ Charges for dental services at our office are due and payable at the time the services are rendered. We accept cash, check, Visa,
MasterCard, Discover and Care Credit. For in-hospital services provided by our doctors, copays and deductible estimates are due at the time of
service and, as a courtesy, we will submit the covered charges to your insurance and allow 45 days for payment. At that time you will be required
to pay the full charges and settle with your insurance company. Please understand that your insurance is an agreement between you and your
insurance company to pay a certain amount for your care. Our bill for services is an agreement between you and our office. You are responsible for
the payment of your bill regardless of the status of your insurance claim. If unusual circumstances should make it impossible to meet our credit
terms, please call or personally discuss the matter with our Financial Manager. This will avoid misunderstanding and enable you to keep your
account in good standing. Mountain Kids Pediatric Dentistry reserves the right to assess finance charges of 18%APR on account balances on a
monthly basis. Accounts 90 days past due are referred to a collection agency, unless prior arrangements have been made with our office. Also, we
will no longer be able to provide for your (dependent) care.
___________ ‘I request that payment of authorized dental or any other applicable health insurance benefits be made either to me or on my behalf
to Mountain Kids Pediatric Dentistry for any services provided to my dependant(s). I authorize any holder of dental/medical information about my
dependant(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 for another time.
If you should have any question regarding the above policies, please feel free to discuss it with our Practice Administrator.
Signature: _______________________________________________
Date:______________________________
Before any dental treatment can be performed for a minor, we must obtain signed permission from a parent or legal guardian. Specific treatment
needs and options will be discussed with parents prior to all dental procedures.
‘As a parent or legal guardian of the above patient(s), I acknowledge that the above information is correct and grant Mountain Kids Pediatric
Dentistry permission to provide my child’s dental and related medical/surgical treatment as deemed necessary, including digital radiographs (x-
rays), diagnostic, restorative, oral surgery, and patient management techniques that are reasonable, necessary and advisable. I also authorize
the administration of anesthetics or analgesics that are advisable by Dr. Guido or Dr. Rusnak, such as nitrous oxide (laughing gas).’
Signature: ______________________________________________________
Date: __________________________________
I give Mountain Kids Pediatric Dentistry permission to take pictures of my child/children for their dental chart. Yes __________ No __________
I give Mountain Kids Pediatric Dentistry permission to display pictures of my child/children in the office.
Yes __________ No __________
Signature: ______________________________________________________
Date: __________________________________
A copy of the Notice of Privacy Practices for Mountain Kids Pediatric Dentistry is available to you; please ask the Receptionist when you arrive if
you would like a personal copy of them. This notice describes how Mountain Kids Pediatric Dentistry may use and disclose your child’s protected
health information, certain restrictions on the use and disclosure of their healthcare information; and rights you may have regarding your child’s
protected health information.
Signature: _______________________________________________________
Relationship to patient: ___________________________
Name of Patient(s): ________________________________________________
_______________________________________________
_________________________________________________
_______________________________________________
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