Tricare Packet | Mitten Kids Dentistry CarePoint

CarePoint Anesthesia Grand Rapids Michigan Pediatric Dentists

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TRICARE PACKET
FINANCE POLICY AGREEMENT with TRICARE BENEFITS

For (Child's) Name:*

Scheduled Appointment:*

The CarePoint Dental Anesthesia Group of Michigan, herein after known as “CarePoint”, is 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 child’s care. We would like to advise you of your financial obligations. Please check below that you have read, understood, and acknowledge this Finance Policy Agreement.

ACKNOWLEDGEMENT

I, the undersigned, certify that I have read, understood, and acknowledge that I have retained a copy of this Finance Policy Agreement. I also understand and acknowledge my financial responsibility for the dental anesthesia services provided by CarePoint Dental Anesthesia Group of Michigan. By signing below, I authorize CarePoint to submit payment for any remaining balance due on or after the date of service. I can alternately provide my card information through CarePoint’s website in the form of a payment.

Parent/Legal Guardian Signature:*

Date:*

Credit Card Payment Authorization

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 Dental Anesthesia Group of MI

Service(s) (LIST ALL)*

One Per Line

Frequency LIMITATIONS*

One Per Line

Proposed Date(s) OF SERVICE*

One Per Line

Estimated Cost OF SERVICES*

One Per Line

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.

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*

Date*

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. 􀀁e 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. 􀀁e information is requested to establish or update infor- mation 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.

NEW PATIENT INTAKE FORM
(with TriCare Benefits)

PATIENT INFORMATION

First Name:*

Last Name:*

Date of Birth:*

Gender:*

Weight (lbs.):*

Height:*

Dental Office Name:*

Contact Number:*

Dental Office Address:*

Primary Physician Name:*

Contact Number:*

(If applicable) Specialist Physician Name:

Contact Number:

PARENT OR LEGAL GUARDIAN INFORMATION

Full Name:*

Contact Number:*

Please check one.*

Mother

Father

Legal Guardian

Other

If other, please explain:

Date of Birth:*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Email Address:*

PREGNANCY / NEONATAL HISTORY

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

YES

If yes, reason(s):

2. Delivery:*

VAGINAL

C-SECTION

If C-Section, reason(s):

3. Was your child premature:*

YES

If yes, born at number of weeks?

4. Were there any complications during the newborn period?

INFANCY / CHILDHOOD / ADOLESCENCE HISTORY

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

YES

If yes, please select type of reaction(s):

RASH

HIVES

EMERGENCY ROOM

OTHER

If other, please explain:

2. Has your child ever been hospitalized?*

YES

If yes, reason?

3. Has your child ever had surgery?*

YES

If yes, reason?

4. Has your child ever had general anesthesia?*

YES

If so, any problems with anesthesia?

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

YES

If so, what problems?

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

Heart Diseases:

Heart Murmur*

YES

WHEN*

MEDICINE/TREATMENT*

High Blood Pressure*

YES

WHEN*

MEDICINE/TREATMENT*

Irregular Heart Beat*

YES

WHEN*

MEDICINE/TREATMENT*

Congenital Heart Defect*

YES

WHEN*

MEDICINE/TREATMENT*

Other Lung Problem*

YES

WHEN*

MEDICINE/TREATMENT*

Other Medical Condtions:

Diabetes*

YES

WHEN*

MEDICINE/TREATMENT*

Kidney Disease*

YES

WHEN*

MEDICINE/TREATMENT*

Seasonal Allergies / Eczema*

YES

WHEN*

MEDICINE/TREATMENT*

GERD / Ulcer / Hernia*

YES

WHEN*

MEDICINE/TREATMENT*

Recurrent Ear Infection*

YES

WHEN*

MEDICINE/TREATMENT*

Seizure Disorder*

YES

WHEN*

MEDICINE/TREATMENT*

Psychiatric Condition*

YES

WHEN*

MEDICINE/TREATMENT*

Genetic Syndrome*

YES

WHEN*

MEDICINE/TREATMENT*

Learning Disability*

YES

WHEN*

MEDICINE/TREATMENT*

Anemia*

YES

WHEN*

MEDICINE/TREATMENT*

Please list any other medical conditions:

** PRE-OPERATIVE GUIDELINES **

Nothing to eat after midnight (this includes gum, candy, or anything other than clear liquids)
Clear liquids (i.e., water, apple juice, Gatorade, 7-Up, or Sprite) can be consumed after midnight, but they must be stopped four (4) hours before the appointment time that was provided to you by the dental office.

** IMPORTANT NOTIFICATION **

A Parent or a Legal Guardian must be present and remain at the dental office during the time of service.

HIPAA AND OUR PRIVACY POLICIES

(The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) addresses the manner in which a Patient’s individual health information may be used or disclosed by Covered Entities (as defined in HIPAA) and other individuals and entities, such as a Provider. For more information regarding your rights under HIPAA, please visit their site at https://hhs.gov/ocr/privacy.)

Please initial below that you have read, understood, and acknowledge the following:

ACKNOWLEDGMENT

I, the undersigned, certify that I have read the above pre-operative guidelines and 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.

Parent/Legal Guardian Signature:*

Date*

CONSENT FOR DENTAL ANESTHESIA SERVICES

The following is provided to inform patients about having treatment under dental 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.

For (Child's Name):*

Scheduled Appointment:*

I, the undersigned, hereby authorize and request any doctor represented with CarePoint Dental Anesthesia to administer anesthesia to my child 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 my child (the patient) has not had anything to eat or drink after midnight (this includes gum, candy, or anything other than clear liquids). Clear liquids (i.e., water, apple juice, Gatorade, 7-Up, or Sprite) can be consumed after midnight, but they must be stopped four (4) hours before the appointment time that was provided to you by the dental office.
I certify that to my knowledge that my child (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.

ACKNOWLEDGMENT

I, the undersigned, consent to the anesthesia deemed appropriate by my child’s 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.

Parent/Legal Guardian Signature:*

Date*

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