FinancialAgreement

Itisourgoalforourpatientstounderstandtheirtreatmentneeds,aswellas,theirfinancialresponsibilitybeforetreatmentbegins.Itisourdesiretomakedentaltreatmentaffordabletoallofourpatients.Pleasereviewthefollowingpoliciesandprocedures:

PAYMENTPOLICY:Paymentisdueatthetimeservicesarerendered.Ifyouhavedentalinsurance,yourestimatedco-payplusdeductibleisdueatthetimeofservice.Ifnoinsuranceisinvolved,paymentisexpectedateachvisit.

1)Weacceptcash,personalchecks,moneyorders,Visa,MasterCard,AMEX,andDiscover.2)Youwillberesponsibleforanyandallcostsincurredinthecollectionofyourdebt(collectionagencyfees,courtfees,and/orattorneyfees)3)Feeswillapplyforanycheckreturnedbythebank4)InthecaseofDIVORCED/SEPERATEDparents,itisYOURresponsibilitytohavefinancialarrangementsmadeaccordingtothedivorcedecreebeforetreatmentbegins.DENTALINSURANCE:Asacourtesy,wewillgladlyfileyourclaimandacceptassignmentofdentalinsurancebenefitsprovidedyouagreetothefollowing:1)Itisyourresponsibilitytoprovideuswithacurrentinsurancecardandallinformationnecessarytoverifycoverage.2)Yourinsurancecontractisbetweenyou,youremployer,andinsurancecompany.WeareNOTapartytothatcontract.Ourrelationshipiswithyou,nottheinsurancecompany.3)AlthoughwemayESTIMATEyourinsurancebenefitswearenotresponsiblefortheiraccuracy.Knowledgeofyourbenefitamounts,limitations,exclusions,waitingperiods,etc.isyourresponsibilityasthepolicyholder.4)Allchargesnotpaidbyinsuranceareyourresponsibilityregardlessoftheirreasonfornonpayment.5)Therearemanyfactorsindeterminingpatientresponsibilitywhencoordinationofbenefits,betweentwoinsurancecompanies,isinvolved.WewillprovideyouwiththemostaccurateinformationavailabletousbutweCANNOTguaranteewhatyouroutofpocketexpensewillbe.6)Pleaseunderstandthatourresponsibilityistoprovideyouwithtreatmentthatbestmeetstheneedofyourchild/children,nottotrytomatchtheircaretoinsuranceplanlimitations.BROKENORMISSEDAPPOINTMENTS:Torescheduleorcancelanappointment,youmustnotifyusasleast24hoursinadvancetoavoidamissedappointmentfeeofupto$50dependingonappointmentlengthand/ornumberofappointmentsmissed.Missedorbrokenappointmentspreventothersfromreceivingthedentalcaretheydeserve.1)Wereservetherighttoterminateprofessionaltreatmentofanypatientwhenscheduledappointmentsarenotkept.

Ihavereadandunderstandthisdocumentinitsentirety;outliningtheofficeandfinancialpoliciesofDr.MichaelVonGruben'sOfficeofPediatricDentistryandagreetotheseterms.SignatureofParent/Guardian:_______________________________________Date:_____________________

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

Iunderstandthat,undertheHealthInsurancePortability&AccountabilityActof1996(HIPAA),Ihavecertainrightstoprivacyregardingmychild’sprotectedhealthinformation.Iunderstandthatthisinformationcanandwillbeusedto:-Conduct,plananddirectmychild’streatmentandfollow–upamongthemultiplehealthcareproviderswhomaybeinvolvedinthattreatmentdirectlyorindirectly-Obtainpaymentfromthird-partypayers-ConductnormalhealthcareoperationssuchasqualityassessmentsandphysiciancertificationsIacknowledgethatIhavereceivedyourNoticeofPrivacyPracticescontainingamorecompletedescriptionoftheusesanddisclosuresofmychild’shealthinformation.IunderstandthatthisorganizationhastherighttochangeitsNoticeofPrivacyPracticesfromtimetotimeandthatImaycontactthisorganizationatanytimetoobtainacurrentcopyoftheNoticeofPrivacyPractices.IunderstandthatImayrequest,inwriting,thatyourestricthowmychild’sprivateinformationisusedordisclosedtocarryouttreatment,paymentorhealthcareoperations.Ialsounderstandyouarenotrequiredtoagreetomyrequestedrestrictions;however,ifyouagreethenyouareboundtoabidebysuchrestrictions.IunderstandIhavetherighttorevokethisconsentexcepttotheextentthatwehavealreadytakenactioncoveredunderthisconsent.IfIchosetorevokethisconsent,Imustdoitinwriting.ContactInformation:Patient’sName:____________________________________________________________________Pleaselistperson(s)withwhomwemaydiscussyourchild’shealthinformation:_____________________________________________________________________________________Pleaselistperson(s)towhomwemayreleasemedicalinformation,includingpickingupprescriptions:_____________________________________________________________________________________Pleaselistperson(s)withpermissiontobringabovepatient(s)toappointmentsandmakemedicaldecisionsifnecessary:______________________________________________________________________________________________________________________________________________________ _________SignatureofParent/Guardian Relationship Date