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Patient Information

Child's Full Name

Preferred Name

Sex

Female Male

Birth Date / Age

School Name

Father

Please Select if Applicable

Stepfather Guardian

Father's Name

Birthdate / Social Security No.

Mailing Address

City/State/Zip

Employer / Work Phone

Phone

Marital Status

Married Single Divorced Separated Widowed

Mother

Please Select if Applicable

Stepmother Guardian

Mother's Name

Birthdate / Social Security No.

Mailing Address

City/State/Zip

Employer / Work Phone

Phone

Marital Status

Married Single Divorced Separated Widowed

With whom does this child reside?

Email Address

Insurance Coverage (We must bill private insurance prior to Medicaid)

#1.

Subscriber Name

#2.

Subscriber Name

Medicaid ID# (WA)

By signing I acknowledge I have listed all Insurance above, I also authorize Moses Lake Pediatric Dentistry to receive direct payment of benefits from my insurance.

Signature

Click to Sign

Date:-------------

Do you have Dental Insurance?

Yes No

Person financially responsible for child’s account:

IN CASE OF EMERGENCY

OTHER THAN THOSE LISTED ABOVE WHOM MAY WE CONTACT?

Phone

Relationship to Patient

How did you hear about our office?

Facebook Google Word of mouth Drive by Dr. Reffered

Does your child have any other Problems, Conditions or Special Needs?

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in strictest confidence and it is my responsibility to inform this office of any changes in my child’s medical status. I authorize Dr. Stanley Cox DMD PS and/or dental staff to perform the necessary dental services my child may need. This may include exams, radiographs, cleanings, topical fluoride treatment, restorative dentistry, oral surgery or limited orthodontics. In order to perform such treatment, our team may recommend the use of local anesthesia (numbing) and/or nitrous oxide (laughing gas).

Parent/Guardian Signature

Click to Sign

Date:-------------

Hippa Policy/Financial Policy

OUR NOTICE OF PRIVACY PRACTICES
By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this Notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office, have copies available in our office, and post it on our web site.

COMPLAINTS
If you think that we have not properly respected the privacy of your child’s health information, you are free to file a complaint with us or the U.S. Department of Health and Human Services, Office for Civil Rights. If you wish to file a complaint, send a written complaint to the office contact person at the address, fax or Email shown at the end of this Notice. If you prefer, you can discuss your complaint in person or by phone.

FOR MORE INFORMATION
If you want more information about our privacy practices, call (509)765-2255 or visit the office.

ACKNOWLEDGEMENT OF RECEIPT
I acknowledge that I received a copy of Moses Lake Pediatric Dentistry’s Notice of Privacy Practices.

In the interest of good communication and our continued commitment to provide the highest quality of dental care available to all of our patients, we have established a Patient Financial Policy. It is our hope that this policy will facilitate open communication between us and help avoid potential misunderstandings, allowing you to always make the best choices related to your child’s care.

We are committed to support you in understanding your child’s dental health, and will always present you with the best dental solution possible to treat your child’s personal situation. To make these services comfortably affordable we are pleased to offer you the following payment options:

Cash, Check, Visa, Master Card, Discover, and Care Credit

We will, as a courtesy, process your insurance benefits in our office. All questions regarding your insurance benefits must be addressed to your insurance carrier.
I agree that I am fully responsible for the total payment of all procedures performed in this office – this includes any treatment that is not a benefit of any dental insurance that my child/children may have. I understand that any estimated portion, not covered by insurance, is due at time of service for all services rendered. I understand that all services are due to be paid within sixty (60) days of date of service, regardless of whether or not my insurance benefits have been received.

Please make your questions and concerns known to our Financial Coordinator who is happy to discuss this policy and ensure that you have an outstanding experience.

Signature

Click to Sign

Date:-------------

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Demographic Information

Patient Information

Parent or Guardian Information

Father

Mother

Insurance Information

Insurance Coverage (We must bill private insurance prior to Medicaid)

Click to Sign

IN CASE OF EMERGENCY

How did you hear about our office?

Medical History

Medical History

Does your child have any history of the following conditions

Dental History

Click to Sign

Hippa Policy/Financial Policy

Hippa Policy/Financial Policy

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Main Header

Demographic Information

Patient Information

Parent or Guardian Information

Father

Mother

Insurance Information

Insurance Coverage (We must bill private insurance prior to Medicaid)

Click to Sign

IN CASE OF EMERGENCY

How did you hear about our office?

Medical History

Medical History

Does your child have any history of the following conditions

Dental History

Click to Sign

Hippa Policy/Financial Policy

Hippa Policy/Financial Policy

Click to Sign

PBHS truForm is best utilized in portrait mode.

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You are in Private Browsing mode.

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