(By furnishing my email address, I consent to the use of email to communicate.)
(By furnishing my email address, I consent to the use of email to communicate)
Primary Insurance Information (typically on abck of card):
Secondary Insurance information (typically on abck of card):
By signing here I acknowledge that I am responsible for this account.
If you have dental insurance your dental benefits are based upon a contract made between your employer and the insurance company. If you have any questions regarding your dental benefits please contact your employer or insurance company directly. It is rare for dental benefit plans to pay for your complete dental care. It is only meant to assist you.
We currently accept many private care insurance plans, this means that we work with literally thousands of companies. Although we do maintain computerized histories of payment by a given company, they do change; therefore it is impossible to give you a guaranteed quote at the time of service. We estimate your portion based on the most up-to-date information we have, but it is ONLY AN ESTIMATE. If you would like to know your insurance benefit, we will be happy to file a "pre-treatment authorization" with your insurance company prior to treatment. Keep in mind this is not a guarantee of coverage. This does delay treatment but will give you the exact out of pocket figures you may require.
We accept assignment of your insurance payment as a service to you. We will bill your insurance as a courtesy, If insurance does not pay within 90 days, Happy Kids Dentistry and Orthodontics reserves the right to request payment in full for services from you and let you collect the insurance funds that are due to you. This is rare but it is important that you recognize that the insurance you have is a legal contract between YOU and your insurance company. Our office is not, and cannot, be a part of that legal contract. Ultimately, you are responsible for all charges incurred in our office.
Happy Kids Dentistry and Orthodontics does require payment in full for your portion at the time of service. We accept MasterCard, Visa, American Express, Discover, cash, and checks. If you are in need of an extended financial options, we also work with Care Credit, who offers 3, 6 or 12 month "same as cash" or longer terms with an interest bearing revolving charge designed to meet your treatment plan needs on approved credit.
A specific amount of time is reserved especially for you and your child. We strongly encourage all patients to keep their appointments. If you must change your appointment, we require 24 hour notice to avoid a $25 cancellation fee.
If you have double coverage. It is required by your insurance company to have an up to date Coordination of Benefits "COB" on file. They may ask you a series of questions to determine which plan is rightfully primary and which plan is secondary. They do at times freeze benefits until this information is received. If payment is not received by the insurance company 90 days after claim submission this will become patient balance. Please ask our staff how to avoid this issue.
I agree with the above conditions. I am granting Happy Kids Dentistry and Orthodontics permission to bill the insurance that has been provided on behalf of my child.
The following are procedures Dr. Eid or one of his associates may perform, please initial after reading, if you have any questions pIease ask us.
Happy Kids Dentistry and Orthodontics would please ask that you stay with your child during appointments. It is required for a child to be accompanied by an adult at all times.
By signing here I acknowledge that I am the responsible party for this child and I have read and understand this consent form and agree to the procedures in which I have provided my initial. All questions regarding the procedures have been answered in a satisfactory manner; and I understand that I have the right to be provided answers to questions which may arise during and after the course of treatment. I further understand that this consent will remain in effect until such a time that I choose to terminate it.
I acknowledge that I have received a copy of the Statement of Privacy practices for the offices of Happy Kids Dentistry. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office healthcare operations. The Statement of Privacy Practices also describes my rights and responsibilities and duties of this office with respect to my protected health information. The statement of Privacy Practices is also posted in this facility. Happy Kids Dentistry reserves the right to change the Privacy Practices that are described in the statement of Privacy Practices. If Privacy Practices change, I will be offered a copy of the revised statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting one be mailed to me.
I permit Happy Kids Dentistry and Orthodontics, their dentists, dental assistants, and other personnel ("Health Care Providers") to discuss health information, in person or by telephone, with the following family members or friends involved in my/my child's care. I also permit the following people to give their consent on my behalf for dental treatment changes, medical history, or urgent matters in my absence: (Please List authorized family members/friends while stating their relationship to the patient below)
Our office is dedicated to protect the privacy rights of our patients and the confidential information entrusted to us. It is a requirement of this practice that every employee receive appropriate training and is dedicated to the principal concept that your health information shall never be compromised. We may, from time to time, amend our privacy policies and practices but will always inform you of any changes that might affect your our obligations and your rights.
We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and Accountability Act and the state of Washington. This includes issues relating to your treatment, payment, and our health care operations. Your personal health information will never be otherwise given or disclosed to anyone -even family members - without your consent or written authorization. You, of course, may give written authorization for us to disclose your information to anyone you choose, for any purpose.
We will only request personal information needed to provide our standard of quality health care, implement payment activities, conduct normal health practice operations, and comply with the law. This may include your name, address, telephone number(s), Social Security Number, employment data, medical history, health records, etc. While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law.
As stated above, we may disclose information as required by law. We are obligated to provide information to law enforcement and governmental officials under certain circumstances. We will not use your information for marketing or fund-raising purposes without your written consent. We may use and/or disclose your health information to communicate reminders about your appointments including voicemail messages, answering machines, and postcards unless you direct us otherwise. We will never use, disclose, sell, or otherwise allow access to your personal, protected information in exchange for or receipt of financial remuneration.
Any breach in the protection of your personal health information, including unauthorized acquisition, access, use, or disclosure, will be fully investigated, addressed, and mitigated as established by the HIPAA Privacy Breach Notification Rule. You have a right to and will be provided all information relating to any breach involving your personal PHI
You have a right to request copies of your healthcare information; to request copies in a variety of formats; and to request a list of instances in which we, or our business associates, have disclosed your protected information for uses other than stated above. All such requests must be in writing. We may charge for your copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately. You can also notify the U.S. Department of Health and Human Services.
If you'd like a full and complete copy of our Statement of Privacy Practices, please ask at the front desk.