Please fill out this form in its entirety. This information is used to determine if office based anesthesia is appropriate for you or your child. All questions must be answered.
Inaccurate or incomplete information may delay your or your child’s care. Provide as much detail as possible.

Do any Blood Relatives have a history of:

Acknowledgment:
I hereby confirm that the information I have provided on this form is accurate to the best of my knowledge and belief. I have not received any advice or instruction  to withhold or falsify any information concerning my or my child’s mental or behavioral health history. I understand that it is my responsibility to furnish all necessary and precise details to enable informed medical decisions for me or my child.

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program requiring all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives, you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.

The following is an explanation of how we are required to maintain the privacy of our health information and how we may use and disclose your health information.

• We may use and disclose your medical records only for each of the following purposes: treatment, payment, and health care operations, and when required by law.
• Treatment means providing coordination or managing health care and related services by one or more health care providers. An example of this would include sending documents to an oral surgeon for a tooth extraction or contacting your pediatrician regarding treatment.
• Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your treatment to your insurance company for payment.
• Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service.
• We may also create and distribute de-identified health information by removing all references to individually identifiable information.
• We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

You have the following rights with respect to your protected health information, which you may exercise by presenting a written request to our Privacy Officer:

• The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
• The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
• The right to inspect and copy your protected health information.
• The right to amend your protected health information.
• The right to receive an accounting of disclosures of protected health information.
• The right to obtain a paper copy of this notice from us upon request.

By signing below, I hereby acknowledge that I have read and understand the above privacy practices.

I hereby authorize and request the disclosure of all health information for the purpose of review and evaluation in the connection with provision of medical treatment and continuity of care. I expressly request that the designated record custodian of all covered entities under HIPAA identified above disclose full and complete protected medical information including the following:

All medical records, meaning every page in my record, including but not limited to: office notes, face sheets, history and physical, consultation notes, inpatient, outpatient and emergency room treatment, all clinical charts, reports, order sheets, progress notes, nurse’s notes, social worker records, clinic records, treatment plans, admission records, discharge summaries, requests for and
reports of consultations, documents, correspondence, test results, statements,
questionnaires/histories, photographs, videotapes, telephone messages, and records received by other medical providers.

I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and drug abuse. I authorize the release or disclosure of this type of information.

This protected health information is disclosed for the purpose of evaluating medical clearance for receiving anesthesia per Central Kentucky Sedation Group protocol.

This authorization is given in compliance with the federal consent requirements for the release of alcohol or substance abuse records of 42 CFR 2.31, the restrictions of which have been specifically considered and expressly waived.

You are authorized to release the above records to:

Central Kentucky Sedation Group
105 Spruce St.
Lexington, KY 40507

I understand the following:

1. I have a right to revoke this authorization in writing at any time by providing written notice to Central Kentucky Sedation Group at the address identified above, except to the extent that information has already been released in reliance upon this authorization.
2. The information released in response to this authorization, except as prohibited by 42 CFR Part 2 or other applicable law, may be subject to disclosure to other parties.
3. My treatment, payment, enrollment, or eligibility for benefits cannot be conditioned on the signing of this authorization.

Any facsimile, copy, or photocopy of the authorization shall authorize you to release the records requested herein. This authorization shall be in force and effect until 90 days from the date of execution at which time this authorization expires.

Central Kentucky Sedation Group is committed to serving the absolute best care to children in the Bluegrass and surrounding areas. We strive to offer our services to as many people as possible. We are proud to be contracted with several of Kentucky’s medicaid companies and are always working to accept more options.

Kentucky Medicaid

We are proudly contracted with the following Kentucky Medicaid companies:

• Aetna Better Health of Kentucky
• Wellcare
• Humana Healthy Horizons
• Molina Passport

If your child has coverage under one of our contracted medicaid companies, your dental practice and our financial team will work hand in hand in the pre-authorization process to get your child’s surgery covered. Should your child not qualify for our services, someone from your dental office will reach out to you to discuss further options. It is your responsibility to inform us of any insurance changes no later than two weeks prior to your child’s dental surgery appointment. We are unable to collect the required pre-authorizations without the correct information. Additionally, if the incorrect information is provided or the patient’s insurance plan(s) have been terminated your treatment estimate will not be accurate and/or the anesthesia costs would become your responsibility.

Fee For Service

If your child does not have medicaid or has insurance that we are not contracted with, you can choose to pay out of pocket.

Our Fee for Service charge for dental rehabilitation general anesthesia is a flat rate fee of $1550. Patients receiving a Frenectomy only will have a flat rate fee of $1350. Payments are required no later than two weeks prior to your child’s surgery. This fee is for anesthesia only. All dental fees will be billed through your child’s dental provider. We accept all major credit cards.

Financial Agreement

By signing this agreement, I acknowledge that I have read and understand the terms and conditions outlined herein. I also confirm that I have received a copy of this agreement for my records.