Please describe some of your goals you have for your child during the following appointments:

To the best of my knowledge, all of the preceding answers and information provided are true and correct.

If my child ever has a change in health, I will inform the Puyallup Pediatric Dentistry at the next appointment without fail.

Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge that I may request a copy of the Notice of Privacy Practices for the offices of Stuart G. Hersey, DDS, MSD. The notice of Privacy Practices describes the types of uses and disclosures of my child’s protected health information that might occur in his/her treatment, payment for services or in the performance of the office’s health care operations. The Notice of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Notice of Privacy Practices is also posted in the facility.

Stuart G. Hersey, DDS, MSD reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Notice of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Notice of Privacy Practices by requesting that one be mailed to me.

 

Additional Disclosure Authority

In addition to the allowable disclosures described in the Notice of Privacy Practices, I here specifically authorize disclosure of my child’s protected health care information to the persons indicated below.

In the event of an emergency, whom should we contact? (other than parents)

The information that I have given is correct to the best of my knowledge. I understand that it will be held in the strictest of confidence, and it is my responsibility to inform this office of any changes in my child’s medical status. I authorize the dental staff to perform the necessary dental services for my minor/child.

I certify that my child is covered by insurance and I assign directly to Dr. Stuart Hersey all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize Dr. Stuart Hersey to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic

Puyallup Pediatric Dentistry

Office Policies

Please review our office policies which we consider guidelines for the practice. We do understand at times there are extenuating circumstances, we will evaluate and accommodate unique situations on a case-by-case basis.

Scheduling and Cancelation

We ask all parents and guardians to reserve appointment times in advance. As a courtesy we will text and/or call to confirm the appointment two business days prior. We ask for the same consideration (two business days) when canceling or rescheduling an appointment.

There is a $50 charge for missed appointments or late cancelations per patient. Should these occur frequently, we may suggest alternate scheduling options or recommend another provider with a schedule that can accommodate your family’s needs.

Record Requests

Please allow 10 business days to process any records request of our office.

Financial

All estimated patient portions are due at the time of service. We extend a 5% cash discount for payments made with cash or check.

Visa, MasterCard, and Discover are accepted; due to fees we incur upon processing we are not able to extend the 5% discount to these forms or payments.

Care Credit is an alternate form of credit that we will accept in office. Please ask for details if alternate payment options are needed. 5% discount does not apply.

Billing

Insurance is billed as a courtesy and we estimate the patient portion from information obtained. When insurance pays less than expected, we will bill any residual monies owing. Residual balances are expected upon receipt. No insurance? We ask for all charges to be paid in full at the time of service.

A $35 fee will be assessed for all checks returned due to non-sufficient funds.

By signing below I understand, acknowledge, accept, and intend to follow these guidelines. If for any reason that I cannot comply, I will notify the office right away.