Tricare Packet | Mitten Kids Dentistry CarePoint

FINANCIAL 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 would also like to inform you of your financial obligations. The following is our company’s financial policy:

FINANCE POLICY: Please check below that you have read, understood, and acknowledge our financial policy.

CarePoint is a “Fee-for-Service” company and payment is due at the time service is rendered.*

I acknowledge

CarePoint is a completely separate entity from your dentist and that all related fees, operative times and/or orders are charged and billed separately.*

I acknowledge

For Pediatric patients (20 years and younger) with TriCare benefits, we require a minimum payment of $1050 (90 minutes or less for anesthesia) due 2 business days prior to your child’s appointment. Payment can be made through our website at www.CPMich.com . Should the dental procedure exceed the allocated 2 hours, an additional $175 per 15-minute increments will be accessed. The remaining balance will be charged to the card on file unless other arrangements have been made. We accept all major credit cards, debit cards, Health Savings Account (HSA), flex spending cards, CareCredit (6-months term), cash, money orders, or checks for our services.*

I acknowledge

A $300 NON-REFUNDABLE fee will be applied to your account in the event that this appointment is cancelled.*

I acknowledge

Please fill out the TriCare form attached to this document. We reserve the right to cancel your child’s appointment if this form is not received prior to the appointment.*

I acknowledge

I certify that I have read, understood, and acknowledge receipt of a copy of the above Financial Policy. I also understand and acknowledge my financial responsibility for the anesthesia services provided by CarePoint Anesthesia Group of Michigan, LLC.

Parent/Legal Guardian Signature:*

Date:*

Patient Name:*

CREDIT CARD PAYMENT AUTHORIZATION

By signing below, you authorize CarePoint to submit payment for any remaining balance due on or after the date of service. Alternatively, card information can be provided through our website in the form of a deposit.

Please Select:

Cardholder Name:

Card Number:

Expiration Date:

CVV:

Cardholder Signature:

Billing Zip Code:

CarePoint Anesthesia Grand Rapids MI Pediatric Dentists Tricare

REQUEST FOR NON-COVERED SERVICES

I am hereby requesting that the following services be provided to me by CAREPOINT ANESTHESIA GROUP

Service(s) (List All)*

e.g. GENERAL ANESTHESIA (in conjunction with dental procedure)

Frequency Limitations*

e.g. 1, 2, etc.

Proposed Date(s) of Service*

e.g. MM/DD/YYYY

Estimated Cost of Services*

e.g. $1050.00

In making this request, I acknowledge that these services are not a benefit of my health coverage under TRICARE and that I will not receive the benefit of the TRICARE Hold Harmless Policy (defined below), which otherwise might apply to me. In addition, I acknowledge that if I have obtained services more frequently than authorized by TRICARE policy, I may be responsible for that professional service.

I also understand that if authorization for this care has been denied by TRICARE, or if reimbursement is denied upon submittal of a claim form, I may appeal the written notification of the denial issued by Health Net Federal Services, LLC/MHN Services.

Unless the decision to deny is overturned as the result of an appeal or dispute, I agree that I will be personally responsible for the payment IN FULL of the billed charges for these services.

Sponsor Name*

Patient Name (Print)*

Sponsor Social Security Number*

Signature of Patient/Legal Guardian*

Sponsor Address*

TRICARE Hold Harmless Policy: A network provider may not require payment from the beneficiary for any excluded or excludable services that the beneficiary received from the network provider (i.e., the beneficiary will be held harmless) unless the beneficiary has been properly informed that the services are excluded or excludable and has agreed in advance in writing to pay for the services.

Privacy Act Statement:

In view of the fact that personal information is being requested from you, notice is hereby given as required by the Privacy Act of 1974. The information is requested and maintained under the authority of Chapter 55, Title 10, United States Code, Section 3101, Title 44, United States Code, and 41 Code of Federal Regulations 101-1100 et seq. The information is requested to establish or update information to control or process claims for payment. Routinely, the information will be used to determine eligibility for TRICARE benefits, review and approve medical care as TRICARE benefits, and to determine reasonable charges/costs of care to be cost-shared under TRICARE. Disclosure of the information is voluntary; however, failure to provide the information may result in denial of benefits.

MEDICAL HISTORY FOR PEDIATRICS

PATIENT INFORMATION:

Last Name:*

First Name:*

Date of Birth:*

Age:*

Height:*

Weight:*

Gender:*

Male
Female

Current General Health Status:*

Excellent
Good
Fair
Poor

Responsible Party:*

Responsible Party DOB:*

Relationship to Patient:*

Tel/Cell:*

Email:*

Mailing Address:*

Dentist/Dental Office:*

Phone:*

Address:*

Primary Physician:*

Phone:*

Address:*

Specialist Physician:

Phone:

Address:

PREGNANCY/NEONATAL HISTORY:

1. Were there any complications during pregnancy or delivery?*

2. Delivery:*

VAGINAL
C-SECTION

If C-Section, reason:

3. Was your child premature:*

NO
YES

If yes, born at how many weeks?

4. Were there any complications during the newborn period?*

MEDICAL HISTORY FOR PEDIATRIC (Cont’d)

INFANCY/CHILDHOOD/ADOLESCENCE HISTORY:

1. Does your child have any allergies to drugs, supplements, or latex:*

NO
YES

Reactions:

RASH
HIVES
EMERGENCY ROOM
OTHER

If other, please explain:

2. Has your child ever been hospitalized?*

NO
YES

If yes, please explain:

3. Has your child ever had surgery?*

NO
YES

Type and Date of Surgery:

4. Has your child ever had general anesthesia?*

NO
YES

Any problems with anesthesia?

5. Has anyone in your family had problems with general anesthesia?*

NO
YES

What problems?

6. List all medications, drugs, and supplements your child is now taking:

7. Has your child ever been treated for, or diagnosed with any of the following conditions?

HEART DISEASES:

Heart Murmur*

NO
YES

WHEN

MEDICINE/TREATMENT

High Blood Pressure*

NO
YES

WHEN

MEDICINE/TREATMENT

Irregular Heart Beat*

NO
YES

WHEN

MEDICINE/TREATMENT

Congenital Heart Defect*

NO
YES

WHEN

MEDICINE/TREATMENT

Other Lung Problem*

NO
YES

WHEN

MEDICINE/TREATMENT

OTHER CONDITIONS:

Diabetes*

NO
YES

WHEN

MEDICINE/TREATMENT

Kidney Disease*

NO
YES

WHEN

MEDICINE/TREATMENT

Seasonal Allergies/Eczema*

NO
YES

WHEN

MEDICINE/TREATMENT

GERD/Ulcer/Hernia*

NO
YES

WHEN

MEDICINE/TREATMENT

Recurrent Ear Infection*

NO
YES

WHEN

MEDICINE/TREATMENT

Seizure Disorder*

NO
YES

WHEN

MEDICINE/TREATMENT

Psychiatric Condition*

NO
YES

WHEN

MEDICINE/TREATMENT

Genetic Syndrome*

NO
YES

WHEN

MEDICINE/TREATMENT

Learning Disability*

NO
YES

WHEN

MEDICINE/TREATMENT

Anemia*

NO
YES

WHEN

MEDICINE/TREATMENT

8. Please list any other medical conditions:

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.

Parent/Legal Guardian Signature:*

Date*

NPO Guidelines for Anesthesia

Nothing to eat after midnight (this includes gum, candy, or anything other than clear liquids)
Clear liquids (water, apple juice, Gatorade, or Sprite) can be consumed after midnight, but they must be stopped 4 hours before the appointment time that was provided to you by the dental office

I certify that:

I have read and understand the fasting guidelines.
CarePoint may communicate patient information using the contact information listed above.

Parent/Legal Guardian Signature:*

Date*

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:

COMMON COMPLICATIONS:

Pain and/or bruising at the IV site
Sore throat and/or hoarseness
Muscle aches
Nausea and/or vomiting

RARE COMPLICATIONS: :

Hearty Injury
Brain damage or death

UNCOMMON COMPLICATIONS:

Headaches
Injuries to lips, teeth, mouth or throat from airway instruments or devices
Unexpected drug reaction
Infection at intravenous site and veins nearby
Bleeding/injury in the nose due to passage of a breathing tube
Lung infection
Eye injury or infection
Weakness in breathing after awakening
Nerve Damage

Alternative options to deep sedation/general anesthesia have been discussed with me and may include the use of local anesthesia with nitrous oxide sedation or local anesthesia alone.
I confirm that the patient has not had anything to eat or drink (other than indicated medications with the smallest amount of water) for at least eight (8) hours prior to anesthesia.
I certify that to my knowledge that the patient is not pregnant or trying to become pregnant.
I have read and agree to the HIPAA Notice of Privacy Practices posted on our website www.cpmich.com.

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.

Patient Name:*

Relationship to Patient:*

Patient's/Legal Guardian Signature:*

Date*

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