PATIENT INFORMATION FORM

PATIENT INFORMATION

CHILD/MINOR INFORMATION (CONFIDENTIAL)
Welcome!

Thank you for choosing Wabash Valley Children's Dentistry. It is our goal to provide your child with the best possible dental care. To help us meet all of your possible dental health needs, please fill out this form. If you have any questions, please ask any of our staff.
Name of Minor/Child*
Date*

MonthDayYear
Date
Gender*

MaleFemale
Birth Date*

MonthDayYear
Date
Social Security #
Address*

Minor/Child Mailing Address

Street Address Line 2

CityState

Zip
Name of School*
School Phone*
Full Names and Ages of Patient's Siblings*

GUARDIAN INFORMATION
Father/Guardian's Name*
Email*
example@example.com
Birth Date*

MonthDayYear
Date
Social Security #
Home Phone*
Cell Phone*
Address*

Mailing Address

Street Address Line 2

CityState

Zip
Employer*
Work Phone*
Mother/Guardian's Name*
Email*
example@example.com
Birth Date*

MonthDayYear
Date
Social Security #
Home Phone*
Cell Phone*
Address*

Mailing Address

Street Address Line 2

CityState / Province

Zip
Employer*
Work Phone*
INSURANCE INFORMATION
Person Financially Responsible For Minor/Child *
Relationship to Minor/Child *
Do you have dental insurance coverage for Minor/Child?*

YesNo
Insurance Company Name*
Address*

Address

Street Address Line 2

CityState

Zip
Phone*
Plan Name*
Group #*
Policy #*

FINANCIAL POLICIES
Please read the following carefully before signing:

1. Payment is due in full at the time services are rendered. As a courtesy, we will gladly file your insurance for you.

2. We accept Personal Checks, MasterCard, Visa, Discover, American Express and Cash. A $50.00 fee plus any bank charges may be charged to your account for any check returned for non-sufficient funds.

3. A monthly service fee plus interest will be charged on all accounts with an outstanding balance after 30 days.

4. Cancellation policy: Our office requires 24 hours notice of cancellation. For any appointment that is not canceled 24 hours in advance, a fee of $50.00 may be charged to your account. As we usually have patients on a waiting list, we appreciate your call if you will need to reschedule your appointment.

5. The responsible party is the parent that brings the child in for the dental visit, independent of what a divorce decree may state. Reimbursement must be made between the divorced parties. We will not intervene.

6. Down payments may be requested and required on special treatment cases requiring sedation, pre-medication, hospitalization or excessive time.

7. Alternative financing can be discussed with you by the office manager if extensive treatment is required.

8. A $50.00 charge plus any bank charges may be assessed for all return checks. We appreciate your cooperation and understanding with this policy. If you have any questions, please ask and discuss it with the office manager.

9. Default Policy: If you fail to meet the financial obligations of Wabash Valley Children's Dentistry you agree to be responsible for collection fees of 40%, attorneys fees and court cost.

PATIENTS COVERED BY MEDICAID and HOOSIER HEALTHWISE

This is to inform you of our current office policy concerning our patients with this type of coverage.

In order to treat patients in a quality manner, we must ask that you cooperate with our office staff in several areas.

1. You must present your current Medicaid card at each appointment. Without your Medicaid card, at each appointment, Medicaid will not allow us to treat your minor/child. We will be unable to see your minor/child for that appointment.

2. You are responsible for all appointments scheduled for your minor/child:

If you fail to show for my minor/child's appointment or you are late, you may be charged a $50.00 fee or you may not be able to schedule a future appointment.

We appreciate your cooperation and understanding with this policy. If you have any questions, please contact our office. I understand, agree to, and accept the above Medicaid policy.

OFFICE PRACTICES

We request that all parents/guardians remain in the reception area during the minor/child's treatment unless special circumstances or parent/guardian assistance is necessary. If we feel that your minor/child has special needs or circumstances develop, we may request your assistance.

There are several reasons for this request. The primary reason is sterility and hygiene. Federal and State laws require us to maintain as sterile a work area as possible. That is why we wear sterile scrubs, masks, and gloves. Secondly, it allows us to work efficiently and effectively without distractions and interference. The doctor-patient relationship will be established and hopefully, the necessary treatment can be completed. If at any time we need parental assistance, the dental assistant will summon the parent for consultation and assistance.
Initial Page By Parent/Guardian*
Please upload image of your insurance card.
AUTHORIZATION
Minor/Child Consent

I am the parent, guardian, or personal representative of the Minor/Child, listed on page 1, and there are no court orders now in effect that prohibits me from signing this consent. I do hereby request and authorize the dental staff to perform necessary dental services for the child named above, including but not limited to x-rays, and administration of anesthetics, which are deemed advisable by the doctor, whether or not I am present when the treatment is rendered.

Insurance Assignment and Release

I certify that the minor/child, listed on page 1, has coverage with the Insurance Company, listed on page 1, and assign directly to the Doctors of Wabash Valley Children's Dentistry all insurance benefits, if any, otherwise payable to us for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

Wabash Valley Children's Dentistry may use your minor/child's health care information and may disclose such information to the above-named healthcare providers, insurance companies and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when the current treatment plan is completed or one year from the date signed

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform the doctor if my minor/child ever has a change in health.
Date*

MonthDayYear
Parent/Guardian Name (Print)*
Relationship to Patient*
Parent/Guardian Signature*

Clear
Initial Page By Parent/Guardian*
WVCD SOCIAL MEDIA RELEASE CONSENT
Authorization for media and/or photographs, videotaping, and interviews*

I authorize Wabash Valley Children's Dentistry, and their representatives or affiliates, to:
- Take and use photographs or films of me/the patient and/or interview me/the patient for the purposes of publicity, education and/or marketing through internal publication, external publication, radio, television, video, social media, or internet publication by Wabash Valley Children's Dentistry.

- Provide my /the patient's name, contact information, and any statements to:
Name of Social Media/ETC if known
Patient Name
Patient Name DOB

MonthDayYear
Parent Name:
Parent Primary Contact Number:
Such photographs, films and/or interview content will disclose the fact that I/the patient have been a patient of Wabash Valley Children's Dentistry and I understand that:
- I am not required to sign this form in order to receive treatment or payment for my care.
- Information used or disclosed under this authorization may be reused by the recipient and may no longer be protected by privacy regulations.
- I may revoke this authorization at any time by notifying Wabash Valley Children's Dentistry, as applicable, in writing, and the revocation will be effective on the date notified (except to the extent action or publication has already been taken based on my earlier authorization, in which case we will attempt to remove the assets from our system but cannot recall uses outside our control).
- This authorization will expire once Wabash Valley Children's Dentistry has finished the publicity, education, and/or marketing activities, unless I have given written notification to revoke my authorization.
I (Name)* have read and understand the above consent. I understand that I have the right to revoke this consent at any time. I understand that this consent has an expiration date of 12 months after signature date.
Parent Signature: *

Clear
Date*

MonthDayYear

WVCD AUTHORIZATION FOR FAMILY COMMUNICATION
I authorize Wabash Valley Children's Dentistry, L.L.C. to release the following information about my minor/child's health care (please initial all that apply):*

Any and all informationInformation necessary to schedule, confirm, cancel or reschedule an appointmentInformation about test resultsInformation about prescriptionsInformation about my bills or accountI grant permission to this individual to bring my child to his/her appointmentOther
Other information (please describe)

This authorization applies to the following individual(s)
Name*
Relationship to Patient/Guardian*
I choose not to authorize any individuals at this time: (Initial)
(Initial)*
I understand that this authorization is valid until revoked by the patient, or the patient's parent/guardian.
Date*

MonthDayYear
Date
Printed Name*
Signature*

Clear
PATIENT'S NAME*
Work on*
By signing below I am confirming that my minor/child's Patient Information, Medical Needs and Insurance Information

has not changed since I updated the patient's paperwork on {workOn}.If there have been changes, I have informed the front desk personnel and updated the proper paperwork.
1. Parent/Guardian's Signature *

Clear
Date*

MonthDayYear
Date
Dear Parents,

Frequently parents ask about dental x-rays. Why are these necessary? How much do these cost? What does the doctor see on x-rays that he cannot see with his eyes? All of these questions will be answered for you. Please ask if you have questions. In our office, we take only those x-rays that are necessary and needed by the doctor to properly treat your child. Secondly, the state of Indiana requires that these x-rays stay in our office for 7 years. There are no charges for copying or transferring of your dental x-rays. Below is the state regulation that requires the doctor to retain these records for your safety and benefit. Thanks for you understanding in this manner.

Respectfully,

Wabash Valley Children's Dentistry, L.L.C
Date*

MonthDayYear
Date
Parent/Guardian's Signature*

Clear
Witnessed
H.B. 1055 Health Care Providers X-ray Maintenance This bill started to be limited to mammograms; however, along the way it was amended to include x-rays taken by all health care providers. All providers participating in the Indiana Medicaid program shall maintain, for a period of seven (7) years from the date Medicaid services are provided, such medical or other records, or both, including x-rays, as are necessary to fully disclose and document the extent of the services provided to individuals receiving assistance under the provisions of the Indiana Medicaid program. At the time the x-ray film is taken, the dentist must either advise the patient or post in the x-ray examination area that all the x-ray films will be kept on file for at least seven (7) years and upon request during that time the patient may have a copy.

Anyone who violates this law is subject to disciplinary action by the licensing board. Effective July 1, 1988.
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PATIENT INFORMATION

GUARDIAN INFORMATION

INSURANCE INFORMATION

MEDICAID/HOOSIER HEALTHWISE INFORMATION

MEDICAL HISTORY

DENTAL INFORMATION

EMERGENCY CONTACT INFORMATION

INSURANCE POLICY

FINANCIAL POLICIES

AUTHORIZATION

WVCD SOCIAL MEDIA RELEASE CONSENT

WVCD AUTHORIZATION FOR FAMILY COMMUNICATION