New Patient Forms - Consents

By signing this form you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations. 

You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice can accompany this consent upon request. We encourage you to read it carefully and completely if you have any questions before signing this consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. 

By signing this form you are giving Just for Kids Dental (Armin Aliefendic, DDS and Associates) consent and authorization to:

1) electronically file any insurance claims generated for reimbursement of dental procedures.

2) receive payment directly to Armin Aliefendic, DDS and Associates of the group insurance benefits otherwise payable to me.

3) release a school or work excuse for dental visits upon request.

4) automatically mail appointment reminder postcards and leave messages on my telephone answering machines.

5) post a picture of my child on the company's bulletin board within the office. 

 

This consent is effective until such a date that the parent/guardian should decide to cancel this consent in writing. With the understanding that information obtained as a result of this consent may be used after the cancellation date. This information will be used only for the purpose it is intended. 

Appointments

We encourage parents to relax in our reception room during the child's visit. This helps us develop a one-on-one relationship of trust and cooperation with your child and allows us to have their undivided attention.

Appointments are scheduled depending on the treatment needed and the age of your child. We will work with you to schedule an appointment at an appropriate time for your child's age and dental requirements. Small children are seen in the morning when they are at their freshest. Older children will be seen in the afternoon. We will not always be able to schedule appointments after school therefore we are always glad to give your child a school excuse. 

The length of appointments is planned exclusively for your child and allows enough time to accomplish the planned treatment. These times are scheduled with the utmost consideration of your child and his/her special needs. It is very important that we are allowed to have the appropriate amount of time we have reserved for your child and may delay the completion of treatment. This will possibly result in the need for another appointment, the child missing school and the parent missing work.

We recognize the value of your time. You can expect us to be on time for you and we would appreciate the same courtesy. We understand emergencies and other unforeseen things happen and occasionally you will need to reschedule an appointment. We request that you give us 24 hours notice for a cancellation of an appointment. This allows us to reschedule your appointment and let another patient have the time originally reserved for your child. 

Financial

While we are committed to giving your child the best dental care available, it is important for you to know approximately what the cost will be. We will give you an estimate based on the treatment prescribed by the Dentist. Remember this is an estimate only. Occasionally, during the course of treatment, other procedures may become necessary. We will keep you informed if there are changes in the estimate. 

We will need your current insurance information and will take into consideration the estimated payment from your insurance company. As a courtesy to you, we will file with your insurance company for the estimated payment. In the event that your insurance does not pay or does not pay as much as expected, you are responsible for the balance on the account.

Payment is expected at the time of service. We accept cash, checks, money orders  and major credit cards (MasterCard, Visa, Discover and American Express). 

I understand that I am financially responsible for all charges whether or not they are paid by the insurance company. 

We know things come up and on occasion broken appointments and late arrivals are unavoidable. During these uncertain times our office has tried to be understanding and flexible with our patients. However, the increasing number of broken and missed appointments has made it necessary for our office to begin enforcing a Broken Appointment Policy effective immediately.

Broken Appointments

- Your appointment time is reserved especially for your family. If your child does not make their appointment, not only are their dental care needs delayed, no one else is able to be treated during that time. When appointments are not kept, dental costs increase for everyone and emergency patients that may have been treated must needlessly wait.
- If an appointment is missed you will be charged a $50 missed appointment fee. The missed appointment fee will need to be paid before you can schedule another appointment.
- If a second appointment is missed you will be charged a $50 missed appointment fee and put on same day scheduling status.
- If a third appointment is missed the patient will be dismissed from our practice. We reserve the right to dismiss any patient family with repeated missed or broken appointments.
- If you absolutely must reschedule and you would like to avoid a broken or missed appointment fee, please call our office at least 24 hours before your appointment. (before 10:00 AM on Saturday for Monday appointments)

 

Late Arrivals

- If you arrive late for your appointment time, we will make every effort to get your child seen. However, if you are late to your appointment by 15 minutes or more, it will be up to the doctor’s discretion whether or not to proceed with the appointment.
- If our schedule allows, we will attempt to have you worked back in to the day’s schedule but your wait time will be increased.
- If you are coming in for treatment, this will directly affect how much of your scheduled treatment will be completed during the visit.

We have found that it is best to be open and honest about what is expected, so that we may provide our patients with the highest quality care at the most reasonable cost possible. We do not want to resort to raising costs, increasing wait time or lowering quality. In return, we ask our patients to honor their commitment to the appointment they scheduled.

Please note: If you know you might be tardy, any notice you can give us prior to your arrival is greatly appreciated.

I have read and understand the above policies.