DUAL INSURANCE AGREEMENT
Welcome to CarePoint Anesthesia Group of Michigan! We are dedicated to providing specialized anesthesia services to the familiar and comfortable environment of your dentist’s office, bringing a tailored and personal touch to your care.
We understand that many patients have more than one insurance policy. Because multiple insurances require different processing guidelines, we would also like to inform you of the dual insurance obligations/responsibilities.
The following is our company’s dual insurance policy:
I certify that I have read, understood, and acknowledge receipt of a copy of the above Dual Insurance Policy. I also understand and acknowledge my financial responsibility for the anesthesia services provided by CarePoint Anesthesia Group of Michigan, LLC if my services are denied by both my private pay insurance and healthy kids insurance.
Dual Insurance InformationPlease complete this form in it's entirety, any missing addresses or policy information will delay the billing process
I, the undersigned, do hereby authorize the release of any medical or other information necessary to process this reimbursement claim.
MEDICAL HISTORY FOR PEDIATRICS
MEDICAL HISTORY FOR PEDIATRIC (Cont’d)
I certify that the above information is complete and accurate to the best of my knowledge. I understand that providing incomplete or inaccurate information may negatively influence my child’s treatment and treatment results. I also certify that CarePoint may communicate patient information using the contact information listed above.
CONSENT FOR ANESTHESIA SERVICES
The following is provided to inform patients about having treatment under anesthesia. The information is not presented to make you more apprehensive, but rather to enable you to better understand the risks and benefits involved with anesthetic treatments.
I, the undersigned, hereby authorize and request any doctor represented with CarePoint to administer anesthesia as previously discussed with me. I understand and agree that procedures not talked about, but deemed necessary for my child’s well-being may be performed to supplement the planned anesthesia. It has been explained to me that all types of anesthesia, although safe, involve some risks and no guarantees can be made concerning results. Serious complications are very rare. The following are complications that may be associated with the anesthetic treatment:
RARE COMPLICATIONS: :
I consent to the anesthesia deemed appropriate by my anesthesiologist. I acknowledge that I have read this form or had it read to me and that I understand the risks, alternatives, and expected results of the anesthetic plan of care.