If your child is a new patient, please call our office at (502) 633-4441 to make an appointment before filling out this form. We are not accepting any new Medicaid/Passport insurance at this time.

**If you answered other, you will be required to provide legal documentation.

We are not accepting any new Medicaid/Passport insurance at this time.

I hereby authorize Dr. Kirby Chamber Hoetker, the covering Dentist, or the dental auxiliaries under her supervision to perform any necessary dental treatment upon my child, including but not limited to the use of local anesthetic, radiographs (x-rays) and/or Nitrous Oxide ("laughing gas"). I understand that no services will be performed without my knowledge.
 

FINANCIAL POLICY 

This statement is to inform you of our financial policy. We are committed to providing you  with the highest quality dental care using only the best material and technology available in  the market today. We are also committed to providing you with up-to-date information and  educational tools so that you may fully participate in maintaining optimum oral health. Our  financial policy is intended to facilitate 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, our patient,  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, regardless of  whether our office is a provider for your insurance company. You may direct your insurance  company to pay your benefits directly to our office by signing the authorization on the  Assignment of Benefits Agreement. In order for our office to file your insurance claim, you  must bring to us a dental insurance form or proof of insurance to be kept on file. 

Payment is due at the time service is provided. Our office accepts cash, personal checks,  MasterCard, and Visa. Outside financing is available through Care Credit upon request and  approval. 

Our office utilizes a collection agency for the management of accounts over 100 days  delinquent. If your account is sent to collections you may be charged a collection fee. 

Returned checks and balances older than 60 days may be subject to collection fees and  finance charges at the rate of 1.5% per month (18% annually). Any returned checks will be  assessed a $25.00 charge. Since your bank must, by law, inform you of a dishonored  check, we will expect you to contact us to make arrangements for settling the full amount  of the check plus $25.00 within ten (10) days. Late payment charges will be assessed if the  matter is not settled by that time. 

If you have any questions regarding our financial policy, please ask. We are committed to  providing you with the most positive experience in dental care.

APPOINTMENT & CANCELLATION POLICY: One parent is permitted to remain with each  child during treatment (other than sedation appointments). Staff will discuss with you the  terms and conditions for this privilege. Other guests/siblings must remain in the waiting  area accompanied by an adult. We require that 48-hour notice be given if you cannot bring  your child for their scheduled appointments. You will be charged $25.00 for broken  appointments when illness is not a factor and 48-hour notice is not given. After a missed  appointment without notice, we may dismiss your child from our practice. Sedation  appointments have a $50.00 broken appointment charge. OR appointments have a  $100.00 broken appointment charge. After a broken appointment, the fee must be paid  before your child will be seen again in the office.

ASSIGNMENT OF BENEFITS AGREEMENT 

Our office will accept an assignment of benefits from your insurance company with the  following provisions. It is important to understand that the contract regarding your dental  benefits is between you, your employer, and your insurance company. The obligation you  have with our practice is to pay for treatment, regardless of the amount that may or may  not be reimbursed by your insurance company. The following provisions identify our  policies governing insurance claims.  

- Although we are willing to complete insurance information forms and submit a  claim on your behalf, we do not accept responsibility for the outcome of the  transaction. Completing insurance forms is a courtesy we extend to you in an effort  to maximize your insurance reimbursement.  

- We require you to sign this form and/or any other necessary assignment documents  that may be required by your insurance company. This instructs your insurance  company to make payment directly to our office.  

- We require you to pay the co-payment and/or deductible, which is the amount not  covered by your insurance company, prior to any service you may receive.  

- Insurance payments ordinarily are received within 30-60 days from the time of  billing. If your insurance company has not made payment to our office within 60  days, we will ask you to pay the balance due at that time. You will be responsible for  seeking reimbursement from your insurance company at that time.  

- Our office does not guarantee that your insurance company will pay for treatment  you receive from our office. We perform routine insurance billing procedures upon  verification coverage. However, if your claim is denied, you will be responsible for  paying the full amount at that time.  

- Our office will not enter into a dispute with your insurance company over any claim,  although we will provide the necessary documentation your insurance company requests to sort out any confusion or questions that may arise. It is ultimately your  responsibility to resolve any type of dispute over payments made or not made by  your insurance company. 

NOTICE OF PRIVACY PRACTICES 

‘THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED  AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION, PLEASE  REVIEW IT CAREFULLY. ‘THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT  TO US. 

OUR LEGAL DUTY: We are required by applicable federal and state law to maintain the  privacy of your health information. We are also required to give you this Notice about our  privacy practices, our legal duties, and your rights concerning your health information. We  must follow the privacy practices that are described in this Notice while in effect. This  Notice takes effect June 1, 2002, and will remain in effect until we replace it. 

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. We reserve the right to make  the changes in our privacy practices and the new terms of our Notice effective for all health  information that we maintain including health information we created or received before  we made the changes. Before we make a significant change in our privacy practices, we  will change this Notice and make the new Notice available upon request. 

You may request a copy of our Notice at any time. For more information about our privacy  practices, or for additional copies of this Notice, please contact us using the information  listed at the end of this Notice. 

USES AND DISCLOSURES OF HEALTH INFORMATION: We use and disclose health  information about you for treatment, payment, and healthcare operations. For example: 

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

Payment: We may use and disclose your health information to obtain payment for services  we provide to 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 activities.

Your Authorization: In addition to our use of your health information for treatment,  payment, or healthcare operations, you may give us written authorization to use your  health information or to disclose it to anyone for any purpose. If you give us an  authorization, you may revoke it in writing at any time. Your revocation will not affect any  use or disclosures permitted by your authorization while it was in effect. Unless you give us  a written authorization, we cannot use or disclose your health information for any reason  except those described in this Notice. 

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

Persons involved in Care: We may use or disclose health information to notify, or assist in  the notification of (including identifying or locating 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 the use or disclosure of your health  information, we will provide you with an opportunity to object to such uses or disclosures.  In the event of your incapacity or emergency circumstances, we will disclose health  information based on a determination using our professional judgment, disclosing only  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 interests in allowing a person to pick up filed  prescriptions, medical supplies, x-rays, or other similar forms of health information. 

Marketing 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 the proper 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 to avert a serious threat to your health or safety or the health or safety of others. 

National Security: We may disclose to military authorities the health information of Armed  Forces personnel under certain circumstances. We may disclose to authorized federal  officials health information required for lawful intelligence, counterintelligence, and other  national security activities. We may disclose to correctional institution or law enforcement 

officers having lawful custody of protected health information of an inmate or patient  under certain circumstances. 

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

PATIENT RIGHTS: 

Access: You have the right to look at or get copies of your health information, with limited  exceptions. You may request that we provide copies in a format other than photocopies.  We will use the format you request unless we cannot practicably do so. (You must make a  request in writing to obtain access to your health information. You may obtain a form to  request access by using the contact information listed at the end of this Notice. We will  charge you a reasonable cost-based fee for expenses such as copies and staff time. You  may also request access by sending us a letter to the address at the end of this Notice. If  you request copies, we will charge you $0.50 for each page, $20 per hour for staff time to  locate and copy your health information, and postage if you want the copies mailed to you.  If you request an alternative format, we will charge a cost-based fee for providing your  health information in that format. If you prefer, we will prepare a summary or explanation  of your health information for a fee. Contact us using the information listed at the end of  this Notice for a full explanation of our fee structure.) 

Disclosure Accounting: You have the right to receive a list of instances in which we or our  business associates disclosed your health information for purposes, other than treatment,  payment, healthcare operations, and certain other activities, for at least six years, but not  before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional  requests. 

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

Alternative Communication: You have the right to request that we communicate with you  about your health information by alternative means or to alternative locations. (You must  make your request in writing.) Your request must specify the alternative means or location,  and provide satisfactory explanation of how payments will be handled under the  alternative means or location you request.

Amendment: You have the right to request that we amend your health information. (Your  request must be in writing, and must explain why the information should be amended.) We  may deny your request under certain circumstances. 

Electronic Notice: If you receive this Notice on our website or by electronic mail (e-mail),  you are entitled to receive this Notice in written form. 

QUESTIONS AND COMPLAINTS 

If you want more information about our privacy practices or have questions of concerns,  please contact us. 

If you are concerned that we may have violated your privacy rights, or you disagree with a  decision that we made about access to your health information or in response to a request  you made to amend or restrict the use or disclosure of your health information or to have  us communicate with you by alternative means or at alternative locations, you may  complain to us using the contact information listed at the end of this Notice. You also may  submit a written complaint to the U.S. Department of Health and Human Services. We will  provide you with the address to file your complaint with the U.S. Department of Health and  Human Services upon request. 

We support 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.  

CONTACT OFFICER 

141 Stonecrest Road 

Shelbyville, KY 40065 

Phone: (502) 633-4441 

Fax: (502) 633-4470 

E-mail: mail@doctorkirby.com

Please sign below if you agree to the following statements:
1. I have received, read, and fully understand Pediatric Dentistry of Shelbyville's Financial Policy and Appointment / Cancellation policy and I accept all provisions.
2. I have received, read, and fully understand Pediatric Dentistry of Shelbyville's Assignment of Benefits Agreement and authorize my insurance company (if any) to pay my dental benefits directly to Pediatric Dentistry of Shelbyville.
3. I have received, read, and fully understand Pediatric Dentistry of Shelbyville's Notice of Privacy Practices. I understand that I may refuse to sign this acknowledgement if I do not agree.

If there are other persons you would like to give your permission to bring your child to Pediatric Dentistry of Shelbyville, and to make dental treatment decisions on your child's behalf, please list them below.