Please check YES or NO.
If “Yes”, please provide Details.

Do any Blood Relatives have a history of:

If yes, please provide the name of the specialist and contact information below.

Name(s) and Number for any Specialists:

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 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 my child.

• Mt. Sterling Pediatric Dentistry has recommended that your child’s dental treatment be completed under general anesthesia. Before your child can go through the approval process, you must complete the Patient Information and Medical History form and sign all necessary consents. Once those have been completed, we will send your child’s information to our anesthesia team, Central Kentucky Sedation Group.
  
  
• Your child will have to be medically cleared by Central Kentucky Sedation Group before he/she is able to be scheduled. This will be completed via phone call. In some cases, the care team may request a well child visit with your pediatrician to ensure the patient is healthy for dental surgery.
• It is very important that Central Kentucky Sedation Group always has the most current contact information available. Please update us immediately if any of your information changes. In the event that Mt. Sterling Pediatric Dentistry or the Central Kentucky Sedation Group is unable to reach you, your child’s appointment may not be scheduled or completed.
  
  
• It is your responsibility to inform us of any insurance changes as soon as possible. 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.
  
  
• Should your child become ill within the 2 weeks prior to surgery, you should contact our office so that we can update Central Kentucky Sedation Group. They will determine if a reschedule is necessary. We do require a doctor’s excuse if your child is sick leading up to or on the date of the procedure in order to reschedule.
  
  
• We do ask that you be available for the entire day of your child’s surgery. While we do try to keep your time at the office minimal, our surgery times may take longer than expected. Most children having dental surgery receive x-rays while under anesthesia which can lead to further dental diagnosis and treatment.
  
  
• We want to be accommodating to all families, but please understand that our surgery times are determined by varying factors and we may not be able to comply with your request.
  
  By signing below, I hereby acknowledge the terms and conditions provided outlined herein.

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:

A. 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.

B. 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. 

C. 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.

Signature of Patient or Authorized Representative

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.

Insurance
Central Kentucky Sedation is contracted with the following Kentucky Medicaid plans:

● Aetna Better Health of Kentucky
● WellCare
● Humana Healthy Horizons
● Molina Passport

If your child is enrolled in one of our contracted Medicaid plans, your dental practice and our financial team will collaborate to identify your benefits and submit claims for you. If your plan does not cover our services, a member of our team will contact you to discuss alternative payment options. Please remember to notify us of any changes to your insurance before your child’s dental surgery appointment, as failing to do so may leave you responsible for the full balance.

Fee For Service
If your child is not enrolled in Medicaid or has insurance that we do not accept, you can choose to pay out of pocket or take advantage of our financing options.

Our fee for general anesthesia is $1,550. For frenectomies under general anesthesia, the fee is $1,350. Payments are due two weeks prior to your child’s dental surgery. This fee covers anesthesia only; all dental procedures will be billed separately through your child’s dental provider. We accept all major credit cards and offer financing through Sunbit.

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

NPOGUIDELINES
● No food of any kind for 8 hours before your arrival time.
● All normal medications should be taken, especially inhalers (e.g. albuterol) or behavioral medications (e.g. Adderall). It is okay to take pills with a small sip of water, unless otherwise instructed by your doctor.

KEYPARENT/GUARDIANINFORMATION
● Your child must be with a responsible adult at all times from when they wake up in the morning until their appointment. Failure to supervise your child before the appointment will result in automatic cancellation.
● You must ensure they do not eat or drink anything during the time restricted time period.
● Do not send your child to daycare/school on surgery day. This will result in automatic cancellation.
● You must remain at the dental office until surgery is complete. If you need to designate consent to another
adult, please let us know in advance. Specific forms of authorization have to be completed or your child’s surgery will be canceled.
● Parent/authorized guardian must be present to sign consent forms.
● If possible, bring a second adult to help you and your child get home safely.
● If possible, do not bring siblings or other children along to the appointment.

WHATTOWEAR/BRING
● Comfortable clothes and shoes
● No nail polish or onesies (footed pajamas)
● Diaper or pullup (if applicable). We do recommend this to all patients age 4 and under, even if they are toilet trained.
● Bring an extra set of clothes
● Bring a small security item (e.g. teddy bear)

SICK OR ON MEDS
● Call us if the child has been sick in the last 4 weeks or has a cough, cold or fever.
● If the child has/uses an inhaler, be sure to bring with you to the appointment. Failure to bring your child’s inhaler may result in your child’s surgery being canceled.

POST-SURGERY
● Due to the anesthetic medication causing prolonged drowsiness, the patient must be accompanied and monitored by a responsible adult until the patient is sufficiently recovered (normally within 24 hours).
● Patients should avoid activities that require physical exertion including but not limited to: playing outside, swimming, riding a bicycle or playing a sport.

*Failure to follow ALL instructions will result in cancellation of your child’s surgery. By signing below, I am hereby acknowledging the terms and conditions outlined herein.

1. The nature and purpose of the operation or procedure, possible alternative methods of treatment, the risks involved and the possibility of complication have all been explained to me. I acknowledge that no guarantees have been made to me concerning the results of the operation or procedure. I understand the nature of the operation or procedure to be: Full Mouth Dental Rehabilitation which may include but are not limited to any of the following procedures: comprehensive oral evaluation, dental x-rays, prophylaxis, crowns (stainless steel, composite, or
zirconia), composite restorations, sealants, space maintenance, and primary or permanent teeth extractions which will be performed by or under the direction of Dr. Emilee Sexton, DMD.

2. I consent to the administration of treatment that may be considered necessary or desirable in the judgment of the dentist performing the procedure and I will not be notified of necessary changes or additions to the procedure until after the procedure is completed.

3. I consent to the administration of general anesthesia in order to complete the above named procedure as given by the medical staff of the medical facility.

4. I consent to the disposal by authorities of any tissues or parts which it may be necessary to remove.

5. The risks involved in the performance of the above described procedure include but are not limited to: pain, bleeding, swelling, infection, dry socket, drug reaction, trismus (limited mouth opening), damage to adjacent teeth and/or restorations, tooth lodged into tissue space, root tip fracture, bone or jaw fracture, temporary or permanent numbness or tingling associated with the lower lip and/or tongue, need for additional procedures, sinus exposure, and reaction to local anesthetic. These risks have been explained to me and I understand them fully.

I have read and had explained to me this consent form and I fully understand the contemplated procedure and the risks involved.

We are setting aside 3-4 hours of our time and the hospital anesthesia team’s time to care for your child’s needs. Cancelling or not showing to a Dental Surgery (OR) appointment prevents us from being able to schedule another child who needs an earlier appointment due to pain or infection. Please be respectful of this.

We understand there may be circumstances in which your child will become ill the day of surgery, we just ask that you call our office at (859)274-4434 as soon as possible. We do require a doctor’s excuse for the day the surgery was cancelled before we can reschedule your child’s Dental Surgery (OR) if you cancel due to illness.

If a Dental Surgery (OR) appointment is broken due to no physical in the appropriate timeframe that was given or cancelling or no showing the day of the surgery, the patient and any siblings will be dismissed from our practice.

If the appointment is missed and notification was not given it could result in any or all of the follow:
• If applicable, we will report failed appointments to the Kentucky Department of
Medicaid services which could result in termination of your child’s insurance.
• Prior to rescheduling we will require an outpatient room reservation fee of $100.00 to be paid upfront and this fee is NOT covered by insurance.
• We reserve the right to terminate your child’s care with our office.
We appreciate your cooperation with this policy and value you're understanding as we strive to provide the best quality care for your children.

I understand that my child is going to have his/her dental work completed under general anesthesia at an outpatient facility by Dr. Emilee Sexton. I understand that while today’s exam found it necessary to have my child treated under general anesthesia, the following may apply: limited oral evaluation and/or inability to get diagnostic radiographs, which could contribute to an incomplete treatment plan. I understand that any additional needs my child may have will be addressed during the surgery to avoid a second operating procedure as recommend by the American Academy of Pediatric Dentistry. I am also aware that I will be finally responsible for any changes incurred to my child’s treatment plan.