Tricare Packet

CarePoint Anesthesia Grand Rapids Michigan Pediatric Dentists


  • REGISTRATION FORM

  • PATIENT INFORMATION:
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  • RESPONSIBLE PARTY:
  • NPO Guidelines for Anesthesia
    • Nothing to eat after midnight
    • 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.
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  • 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​ acknowledge ​below that you have read, understood, and acknowledge our financial policy.

  • 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.

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  • 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.

  • 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

  • e.g. GENERAL ANESTHESIA (in conjunction with dental procedure)
  • e.g. 1, 2, etc.
  • e.g. MM/DD/YYYY
  • e.g. $750.00
  • 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.

  • 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.

    Last Updated 08/12/2020 TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. HF00917x057 (08/20)


  • MEDICAL HISTORY FOR PEDIATRICS

  • PATIENT INFORMATION:


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  • PREGNANCY/NEONATAL HISTORY:

  • MEDICAL HISTORY FOR PEDIATRIC (Cont’d)

  • INFANCY/CHILDHOOD/ADOLESCENCE HISTORY:

  • HEART DISEASES:

  • LUNG DISEASES:

  • OTHER 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.

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  • 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.

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  • This field is for validation purposes and should be left unchanged.