FINANCIAL RESPONSIBILITY & APPOINTMENT POLICY

Thank you for choosing Great Beginnings Pediatric Dentistry for your child’s dental home! We are pleased to welcome you to the practice! We know how important the health of your child is, and we are grateful you have entrusted us with their care.

It is our policy to make definite financial agreements with you before any treatment starts. Please understand that payment of your bill is considered a part of your child’s treatment.

All co-payments and deductibles are to be paid the date services are rendered. You are responsible for paying all charges not covered by your insurance company, including all fees considered above your insurance carrier’s usual and customary fee schedule. Your insurance benefits are a contract between you and your employer. The amount of coverage you receive depends on the type of plan chosen by you and/or your employer. Please be aware that the parent bringing the child to Great Beginnings Pediatric Dentistry is legally responsible for payments of all charges. Independent of what a divorce decree may state, we cannot send statements to other persons.

For your convenience --and in an effort to be a hands-free document office-- we do NOT accept cash or checks. We DO accept Google Pay, Apple Pay, Visa, MasterCard, Discover and American Express (numbers kept on file), Health Savings Accounts, and Care Credit (you can apply directly on our website under the Patient Resources - Financing Options

Dental Insurance: We strongly encourage you to thoroughly review your insurance plan and guidelines/booklets prior to each appointment. As a courtesy to our patients, if we have received all of your insurance information by the  scheduled appointment date, we will gladly process your claim. We request that you pay your ESTIMATED portion when services are rendered. Any amount not covered by your insurance or any

difference in the estimated portion is the parent’s or legal guardian’s responsibility. Our office will file your insurance a maximum of two times per claim. We will only file secondary insurance claims to our in-network plans, Anthem PPO and Delta Dental. For other secondary insurance plans, we will gladly provide you with an insurance claim form to submit. If a primary or secondary claim is not paid by your insurance

carrier within 45 days, you will be responsible for the full balance and any further insurance appeal is your responsibility.

Your health and safety are our top priorities. Therefore, we will only be seeing healthy patients in our office. If your child or anyone in your immediate household has a fever or flu-like symptoms, we kindly ask you to reschedule. Furthermore, all patients will be screened for illness upon arrival. Anyone with a fever of 100°F or above will be asked to leave and reschedule. No fees will be charged for these cancellations.

Cancellations Not Due to Illness: In consideration of all our patients, we request at least 48 hours’ notice prior to the change of appointment for non-illness related reasons. We reserve the right to charge a $50.00 fee for any missed appointments or cancellation/change made with less than 48 hours’ notice. If your child misses two appointments, an appointment reservation fee of $50.00 will be required and collected before future appointments. We also  request a $50.00 reservation fee if two or more family members have treatment on the same day.

Checking In Upon Arrival: Please stay in your car.

When you arrive in our parking lot, please text your child's first name, last initial, and HERE to (330) 333-0068 to report your arrival to our front desk. Please remain in your car until a team member texts or calls you back to let you know it is time for you to enter the office. There will be NO reception area. When you are cleared to enter, all who enter our doors are asked to wear a mask or face covering in order to protect other families and team members in our office.

We strive to provide our patients with the best possible care. Late arrivals cause schedule delays for other patients and reduce the amount of time we have to address your child's needs. We will always do our best to accommodate late arrivals into the schedule if time permits, but please be aware that if all treatment cannot be completed in the time allotted, your child will be re-appointed for another scheduled time. During the school months, late afternoon and early morning appointments are in high demand. We do our best to reserve these hours for the school-aged patients, and we ask all of our patients to understand when we need to appoint during school hours. We will gladly provide you with an excuse note for your child's school.

My signature below indicates my authorization and agreement to the following:

I authorize Great Beginnings Pediatric Dentistry to release any information concerning my child to our insurance company.

I have read Great Beginnings Pediatric Dentistry’s Financial and Appointment Policy and agree to the terms set forth in its contents.

and authorize Great Beginnings Pediatric Dentistry for my child’s dental care. This I request consent includes an examination, cleaning, and any necessary dental treatment.

I further request and authorize the taking of dental x-rays, as may be considered necessary for the diagnosis and/or treatment of my child’s dental concern. I will allow photographs to be taken of my child or child’s teeth for diagnostic or educational purposes.

I understand that dental treatment for children include efforts to guide their behavior by helping them to understand the treatment in terms appropriate for their age. The team at Great Beginnings Pediatric Dentistry will provide an environment likely to help children learn to cooperate during treatment by using praise, explanation, demonstration of procedures and instruments, and variable voice tone.

I will be responsible for any charges incurred on this child for dental treatment.

This notice describes how health information about you may be used and disclosed and how you can get access to this information.

Please review carefully: We are required by applicable federal and state law to maintain the privacy of your health information. We must allow the privacy practices that are described in this notice while it is in effect.

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.

You may request a copy of our Notice at any time. For more information about our privacy practices, please use the information listed at the end of this Notice.

Access: You have the right to look at or get copies of your health information, with limited exceptions. You must make a request in writing to obtain access to your health information. A form will be provided to you for this request. We will charge you a reasonable cost-based fee for expenses such as copies, staff time, and postage.

Disclosure Accounting: You have the right to receive a list of instances in which we disclosed your health information for other than treatment, payment, healthcare operations, and certain other activities for at least six years, but not before 4/14/03.

Restriction: You have the right to request that we placed additional restrictions on our use and disclosure of your health information. We are not required to agree to these additional restrictions, but if so, we will abide by our agreement (except in an emergency

Amendment: You have the right to request in writing that we amend your health information. We may deny your request in certain situations.

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative locations. This request must be in writing and spell out the means and/or locations.

Uses and Disclosures of Health Information: We use and disclose health information about you for treatment, payment, and healthcare operations.

Treatment: We may use or disclose your health information to a physician or other healthcare provider treating you.

Payment: We may use and disclose your healthcare information to obtain payment for the 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 healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing services.

Your Authorizations: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorizations to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may receive it in writing at any time.

Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of a family member, or assist in the notification of 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 incapacity or emergency circumstances, we will disclose your 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 inferences of your best interest in allowing a person to pick up x-rays or other similar forms of health information.

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 another person to the extent necessary to help with your healthcare or with payment to your healthcare, but only if you agree that we may do so.

Marketing and 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 or safety or the health or safety of others.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters

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 our decision concerning alternative means or locations or to your request made to amend or restrict the sharing of your health information, you may complain to us using the contact information listed below. You also may submit a written complaint to the U.S. Department of Health and Human Services upon request. We suppler 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.

My signature below indicates all of the following:

I am the custodial parent/legal guardian or authorized caregiver of the noted patient. On behalf of the patient noted, I authorize Great Beginnings Pediatric Dentistry to release any information concerning my child to our insurance company. I have read and accept the Privacy Practice Policy (HIPAA), I understand it and agree to the terms set forth regarding payment.

By signing this “Authorization to Photograph and Use Image” Consent Form (the “Consent Form”), I agree to permit Great Beginnings Pediatric Dentistry (the “Practice”) , located at 9964 Vail Drive, Suite 1, Twinsburg, OH 44087 to do all of the following:

1.Take photographic images and/or video record (the “Images”) one or more of my children, each of

whom is a patient of the Practice; and 2.Use the Images for marketing purposes, including but not limited to:

a.Posting to the Practice’s website; b.Print advertising in local newspapers or other media; c.Use for hard-copy brochures and/or newsletters relating to the Practice; and/or d.Posting hard-copy on a bulletin board or other location at the Practice site located at e.Posting to social media outlets, including but not limited to, Facebook, Instagram, and YouTube

The Practice will not use the Images for any other purposes except as expressly set forth in this Consent Form. You may revoke your authorization for the Practice to use the Images at any time by providing written notice of such revocation to the Practice at the Practice’s address as set forth above. In the event of such revocation, the Practice will cease using the Images on a going forward basis. To the extent the Practice has already placed advertisements, created brochures or other materials using the Images prior to its receipt of your revocation, you agree that the Practice may continue to use such advertisements, brochures or other materials – but shall cease any further creation of materials using or containing the Images.

I HAVE READ THIS CONSENT FORM AND HEREBY AUTHORIZE GREAT BEGINNINGS PEDIATRIC DENTISTRY TO TAKE PHOTOGRAPHIC IMAGES OF MY CHILD/CHILDREN (NAMED BELOW) AND TO USE SUCH IMAGES AS SET FORTH IN THIS CONSENT FORM.

I am completing this form in order to grant permission to the the adult person(s) listed below to accompany my child to the office of Great Beginnings Pediatric Dentistry for dental appointments and to make any necessary decisions regarding dental treatment for my child, including, but not limited to, the following: The consent for this authorized person to sign any and all forms required to give permission to Great Beginnings Pediatric Dentistry to treat the dental needs of my child The consent to the dental practice to discuss finances (treatment charges, account balances, next visit charges) with this authorized person The consent to the dental practice to discuss my child’s future dental treatment needs (i.e., treatment plans) The consent for this authorized person to sign my child’s treatment plan once it has been presented by the dental staff. I understand this does not obligate me to the treatment, only that the office has informed me or the authorized representative to the dental needs of my child The consent for this authorized person to schedule future dental visits for my child

I understand this consent will be valid for the duration of my child’s status as a patient of Great Beginnings Pediatric Dentistry, or until I rescind this agreement in writing.