Palmdale Children's Dental

APPOINTMENT CANCELATIONS REQUIRE 24 HOURS NOTICE.

1. IF YOU MISS TWO OR MORE APPOINTMENTS WITHIN 12 MONTHS WITHOUT GIVING 24 HOURS NOTICE, PATIENT WILL BE DISSMISSED.

2. VERBAL CONFIRMATION IS REQUIRED THE DAY PRIOR TO YOUR APPOINTMENT. WE WILL CALL AND LEAVE A MESSAGE BUT FAILURE TO MAKE CONTACT MAY RESULT IN MOVED OR CANCELLED APPOINTMENTS.

3. IF YOU HAVE A CHANGE IN ADDRESS OR INSURANCE INFORMATION, PLEASE NOTIFY US IMMEDIATELY SO WE MAY UPDATE THE INFORMATION IN YOUR FILE.

4. FULL PAYMENTIS REQUIRED AT THE TIME OF SERVICE UNLESS OTHER ARRANGMENTS ARE AGREED UPON. WE ACCEPT ALL CREDIT CARDS AND CASH PAYMENTS. IF THERE IS DENTAL INSURANCE COVERAGE, THE OFFICE WILL BILL THE INSURANCE. HOWEVER, REMEMBER THE PAYMENT IS STILL YOUR RESPONCIBILITY IN THE EVENT OF DENIALS FROM YOUR INSURANCE.

5.  PLEASE READ AND CHECK YOUR MONTHLY STATEMENT CAREFULLY. IF YOU DO NOT RECEIVE YOUR BILLING STATEMENT BY THE 15TH OF THE MONTH, PLEASE CONTACT OUT OFFICE.

6. THERE IS A SERVICE CHARGE OF $25 FOR ANY RETURNED CHECKS

7. THE FOLLOWING POLICY WILL BE STRICTLY ENFORCED. ACCOUNTS NOT PAID WITHIN 60DAYS WILL BE CONSIDERED OVERDUE AND APPROPIATE ACTION WILL BE TAKEN. YOUR ACCOUNT WILL BE SENT TO A PRIVATE COLLECTIONS COMPANY. (UNLESS SPECIFIC ARANGMENTS HAVE BEEN MADE)

 

I AM AWARE THAT PALMDALE CHILDREN’S DENTAL WILL BE BILLING MY INSURANCE AND RECEIVING PAYMENT

 

THE GUARDIAN THAT IS PRESENT FOR THE CHILD’S APPOINTMENT IS RESPONSIBLE FOR THE CHILD’S ACCOUNT.

I HAVE READ THE ABOVE AND AGREE TO ABIDE BY THE POLICIES IN THIS OFFICE

I understand that as a part of my child’s healthcare, this organization originates and maintains health records describing my child’s health history, symptoms, examination, test results, diagnoses, treatment and any plans for future care or treatment. I understand that this information serves as:

• A basis for planning my care and treatment

• A means of communication among the many health professionals that contribute to my care

• A source of information for applying my diagnosis and surgical information to my bill

• A means by which third-party payer can verify that services billed were actually provided

• And a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals

I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their notice and practices and prior to implementation will mail a copy of any revised notice to the address I’ve provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.

 

Your care is important to us, and we feel it is vital to your treatment that we communicate openly and honestly.

As such, we request that you: Ask questions and participate in your care, be honest about your history, symptoms, and other important health information, prepare for and keep scheduled visits, and be respectful to our office staff and healthcare providers.

In exchange, we agree that we will: Explain diagnosis, treatment recommendations, and outcomes in an easy-to-understand way, listen to your questions and help you make decisions about your care, keep discussions and records private, and determine when a referral or termination of care is appropriate.

MEDIATION

As a part of our emphasis on open communication, we ask our patients to sign this mediation agreement. While we do not anticipate any issues or concerns during the course of your treatment, if any arise, you (and/or your legal counsel) and your healthcare provider (and/or their legal counsel) agree to meet with a neutral mediator and work toward a solution. Whether or not a solution is found, mediation may postpone but does not remove or block your legal rights. Importantly, you agree that any usage or inference to a "claim" will be understood and read as "potential claim" until the mediation is complete. This designation allows us to begin in a less formal manner that has been shown to expedite the resolution process. Your signature on this page confirms that should a concern arise in any aspect of the care provided by this office, staff, and affiliated healthcare professionals, you agree to mediate first before pursuing legal action.

 

EXPERT WITNESSES

Further, if after mediation, you still wish to pursue a court action relating to your care, your signature on this page confirms that you will use, as your expert witness(es) in your legal action, American Board of Medical Specialties board-certified medical witness(es) in the same specialty as Physician. Furthermore, you agree that the physicians who you select will be in good standing and adhere to all of the rules and guidelines of professional conduct of the American Board of Medical Specialties.

As consideration for this agreement, we agree that we will adhere to these same guidelines in selecting our expert witness(es) for any court action relating to your care.

I certify that I have read or had read to me the contents of this form. I understand the possible advantages that compliance with professional healthcare recommendations can provide as well as potential consequences of non-compliance. I attest that I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction.