Sansone Family Dental LLP -Child Form

WELCOME

Sansone Family Dental Practice LLP - Child Form Packet
Sansone Family Dental Practice, L.L.P.
David F. Sansone, D.D.S.
Thomas R. Sansone, D.D.S.
4343 Dewey Avenue
Rochester, NY 14616
585-663-1390
We would like to welcome you and your child to our office. Our goal is to make every child's visit pleasant and educational. Our practice is based on preventive care. We strive to teach good oral care that will enable your child to have a beautiful smile that lasts a lifetime.
Tell Us About Your Child
Today's Date

MonthDayYear
Date
Child's Name

First NameMILast Name
Nickname
Sex

MaleFemale
Child's Birthdate

MonthDayYear
Childs Age
School
Grade
Child's Home Phone #
Please enter a valid phone number.
SS #
Child's Home Address

Street Address

Apt/Condo #

CityState

Zip Code
Email Address
example@example.com

Guardian #1 Information
Choose the applicable option:

MotherStep MotherGuardian
Name
Birthdate

MonthDayYear
Email Address
example@example.com
Cell #
Please enter a valid phone number.
Home #
Please enter a valid phone number.
Employer
Work #
Please enter a valid phone number.
SS #
DL #
Guardian #2 Information
Choose the applicable option:

FatherStep FatherGuardian
Name
Birthdate

MonthDayYear
Email Address
example@example.com
Cell #
Please enter a valid phone number.
Home #
Please enter a valid phone number.
Employer
Work #
Please enter a valid phone number.
SS #
DL #

Person Responsible For Account
Name
Relation
Billing Address

Street Address

Street Address Line 2

CityState

Zip Code
Work Phone #
Please enter a valid phone number.
Ext
Home Phone #
Please enter a valid phone number.
Employer
DL #
SS #
Who is responsible for making appointments?
Name
Work Phone #
Please enter a valid phone number.
Ext
Home Phone #
Please enter a valid phone number.

Insurance Information
Primary Dental Insurance
Insurance Co Name
Insurance Co Address
Insurance Co Phone #
Please enter a valid phone number.
Group # (Plan, Local or Policy #)
Policy Owner's Name
Relationship to Patient
Policy Owner's Birthdate

MonthDayYear
ID #
Policy Owner's Employer
Orthodontic Coverage?

YesNo
Secondary Dental Insurance
Insurance Co Name
Insurance Co Address
Insurance Co Phone #
Please enter a valid phone number.
Group # (Plan, Local or Policy #)
Policy Owner's Name
Relationship to Patient
Policy Owner's Birthdate

MonthDayYear
ID #
Policy Owner's Employer
Orthodontic Coverage?

YesNo

HIPAA and Notice of Privacy Practices
I understand that, under the Health Insurance Portability & Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
- Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
- Obtain payment from third-party payers.
- Conduct normal healthcare operations such as quality assessments and physician certifications.
I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Private Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
Patient Name
Relationship to Patient
Signature

Clear
Date

MonthDayYear
Date

Consent for Disclosure of Health Information
PATIENT NAME
We will use the following methods to contact you in order to conduct business relating to your dental/medical treatment, including, but not limited to, appointments, reminders, medical results, billing and/or insurance questions:

Home Phone, Work Phone, Cell Phone, Text Message, With another person, Via mail, Via email/electronically.
Please indicate below if there are any methods you do not want us to use
Is there a family member, friend, or person responsible for your care that you would like us to be able to communicate with regarding your treatment and/or information from this office? If so, please list below:
Person 1:
Name
Relationship
Person 2:
Name
Relationship
Person 3:
Name
Relationship
Patient Signature

Clear
Parent/Guardian Signature (If Applicable)

Clear
Date

MonthDayYear
Date

Financial Policy
Thank you for choosing us as your dental care provider. The following is a statement of our Financial Policy which we ask you to read carefully and sign prior to treatment.
REGARDING INSURANCE
Your insurance policy is a contract between you and your insurance company.
It is our policy to charge our patients and their insurers in a fair and consistent manner. Our fees are set at usual and customary rates for this area.

All insurance information including changes and updates need to be provided to us at the time of service.

Payment in full is due at the time services are rendered. We will submit all claims to your insurance company electronically to expedite their direct reimbursement to you. Please note some, and perhaps all, of the services provided may be non-covered under your insurance plan.

If you have more than one dental insurance policy, upon receipt of payment from primary insurance carrier, please send the explanation of benefits to us and we will gladly submit to your secondary insurance carrier for you.
PAYMENTS
We accept cash, checks, American Express, Discover, Mastercard, and Visa. We also accept Care Credit. Should you make a payment by check, and it is returned unpaid, a fee of $50.00 will be charged to your account.
BROKEN APPOINTMENTS
There will be a fee based on visit type for broken appointments or cancellations not made 24 hours in advance of the appointment.

In the event that Sansone Family Dental Practice, L.L.P. pursues civil remedies against me for the collection of my financial obligations for services rendered, I hereby agree to be responsible for reasonable collection and/or attorney fees and disbursements incurred by Sansone Family Dental Practice, L.L.P. I have read this Financial Policy and understand and agree to be personally and fully responsible for payment.
PATIENT NAME (Legal Guardian if under 18 years of age)
SIGNATURE

Clear
DATE

MonthDayYear
Date
Should be Empty:

	Yes	No
Latex
Metals/Nickel
Plastic

	Yes	No
Abnormal Bleeding
ADD / ADHD
Any Hospital Stays
Any Operations
Artificial Bones / Joints
Asthma
Cancer
Congenital Heart Defect
Convulsions / Epilepsy
Diabetes
Handicaps / Disabilities
Hearing Impairment
Heart Murmur
Hemophilia
Hepatitis
HIV+ / AIDS
Kidney / Liver Problems
Rheumatic / Scarlet Fever
Sickle Cell Disease / Traits
Tuberculosis (TB)

	Yes	No
Lip Sucking / Biting
Speech Problems
Nail Biting
Thumb / Finger Sucking
Mouth Breather
Tongue Thrust
Nursing Bottle Habits
Clenching / Grinding Teeth

WELCOME

Tell Us About Your Child

Who Is Accompanying The Child Today?

Guardian #1 Information

Guardian #2 Information

Person Responsible For Account

Who is responsible for making appointments?

Insurance Information

Dental History

Dental History (Continued)

HIPAA and Notice of Privacy Practices

Consent for Disclosure of Health Information

Financial Policy

REGARDING INSURANCE

PAYMENTS

BROKEN APPOINTMENTS