Happy Kids Pediatric Dentistry
Dr Cruz Maria Ceino
“Where Magical Smiles Begin”
Patient Information
Person Financially responsible for account
Has your child ever been diagnosed with or treated for the following?
I, the undersigned parent/legal guardian of this child, certify that the above is accurate and complete to the best of my knowledge. I will notify Dr. Ceino and/or the staff of any changes in the above prior to appointment.
We reserve your appointment time specifically for you. If you need to reschedule please give us at least 48 hours notice not including weekends so that we may give someone else the opportunity to utilize that time.
A fee will be charged for late cancellations and/or missed appointment depending on the length, $30 per 30 minutes.
Consent for Dental Treatment
I, the undersigned parent/legal guardian, hereby give consent for Dr.Ceino and staff to examine
this child, clean his/her teeth, perform all necessary dental treatment, administer local anesthetics, apply topical fluoride, take diagnostic radiographs, take clinical photographs and other records necessary for an accurate diagnosis for my child. I understand that dental treatment for children involves behavior guidance which may include the use of praise, explanation or demonstration of procedures and instruments, variable tone voices, mouth props, nitrous oxide, or protective stabilization when necessary to promote cooperative behavior and a
positive experience and to protect the child from potential injury.
This financial agreement is intended to facilitate our ability to provide excellent service to you while minimizing our administrative costs. All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you and not with your insurance company. Your insurance policy is a contract between you, your employer, and the insurance company. Our office is not a party to that contract. If payment from your insurance company is not received within 60 days from the date of service, you will be expected to pay the balance in full. As a courtesy to you we will help you process all your insurance claims. In order for our office to file your insurance claim, you must bring a complete dental insurance form or proof of insurance at each appointment. Your estimated copayment for treatment which is the amount not covered by your insurance is due at the time of service is provided. Your co-payment may be adjusted after the time of service depending upon final reconciliation of insurance payment.
Our office accepts cash, Master Card, Visa, and Discover. Outside financing is available through care credit upon request and approval. Returned checks and balances older than 60 days will be subject to collection fees and finance charges at the rate of 1.5% per month. Please do not hesitate to ask if you have any questions regarding this financial agreement.
Notice of Privacy Practices: HIPPA
Disclosure of Health Information
We use and disclose health information about your child for treatment, payment, and health operation. We may disclose your child’s information to a health care provider treating him/her via telephone, mail, or e-mail. You may give us written authorization to disclose health information for any purpose. This authorization may be revoked in writing. We need written permission before any health information is disclosed any caregivers besides the child’s legal guardian. In the event of any emergency, we will disclose information based on our
professional judgment. We may use your child’s health information to obtain payment for services. We will not use health information for marketing purposes. If we suspect a possible victim abuse, neglect, or domestic violence, we may disclose your child’s health information as the law requires. We may disclose your child’s health information to provide you with an appointment reminder/confirmation or treatment recommendation (such as voicemails, postcards, e-mails, or letters).
Appointment Reminders
We may email you or leave a message with a person or an answering machine/voicemail to reconfirm appointments. These emails/messages will be of non-sensitive nature and will include the doctor’s name and/or the practice name. You may inform us in writing if you prefer to not to have emails/messages of this nature left for you.
Access: You have the right to look at or obtain your child’s health information. If you request copies, we will charge you for each page, for staff time to locate and copy of information and postage if you request it to be mailed.
Restriction: You have a right to request that we place additional restrictions on our use or disclosure of information.
Alternative Communication: You have the right to request that we communicate with you about your health history in alternative means.
Amendment: You have the right to request that we amend your child’s health information. We may deny your request under certain circumstances.
If you are concerned that we may have violated your child’ privacy rights or disagree with a decision we made about access to your child’s health information you may submit a written complaint to the U.S. Department of Health and Human Resources.
