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It is our practice policy that every patient is accompanied by a Parent or Legal Guardian for the First Visit. Legal guardians, including adoptive or step-parents, must bring along paperwork which establishes legal guardianship so we may keep a copy in the patient’s file. If a Parent or Legal Guardian will not be able to attend the first visit, please contact us so we may reschedule the appointment or to consider additional options.

Welcome

I understand the information that I have given is correct to the best of my knowledge, 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 my child may need and I am responsible for the cost of this treatment at the time of visit unless prior arrangements have been made.

HIPAA FORM

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

• Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
• Obtaining payment from third party payers (e.g. my insurance company);
• The day-to-day healthcare operations of this practice.

I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I may revoke this consent in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.

Important Dental Insurance Information

Understanding your insurance benefits can be quite challenging. Our goal is to assist you in obtaining your maximum dental benefits. We care for patients whose parents or legal guardians are employed by hundreds of different companies. Each company pays an insurance premium for specific coverage, which fits each employer's budget for the year. Traditionally, these coverages can change from year to year. They do not notify us of any changes in your specific policy. It is absolutely necessary that you become familiar with your network, policy, exclusions, deductibles and required co-pays. For instance, some insurance companies do not cover white fillings, some companies have age restrictions, etc. You will be asked to approve all treatment your child may need. It will be your responsibility to cover all payment differences between the office fee and the amount of your insurance reimbursement.

I hereby authorize Pediatric Dentistry of Brandon, PA, to release to my insurance company any information acquired in the course of my child's dental care. I hereby authorize benefits to be paid directly to Dr. Jorge Torres and Pediatric Dentistry of Brandon, PA.

I understand that I am responsible for any unpaid balance.