Tricare Packet | Mitten Kids Dentistry CarePoint

CarePoint Anesthesia Grand Rapids Michigan Pediatric Dentists

REGISTRATION FORM
PATIENT INFORMATION:
Last Name:*
First Name:*
Date of Birth:*
MM slash DD slash YYYY
Gender:*
- M
- F
Weight (LBS):*
Height:*
Name of Dental Office:*
Appointment Date:*
MM slash DD slash YYYY
RESPONSIBLE PARTY:
Name:*
Relationship to Patient:*
Tel/Cell:*
Email:*
Mailing Address:*
PAYMENT INFORMATION:*
- Healthy Kids
- BCBS/Delta Dental
- Self-Pay (Please complete Financial Agreement on page 2.)
ID #
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.
Parent/Legal Guardian Signature:*
Date*
MM slash DD slash YYYY
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.
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 $750 (2 hours 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 $90 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:*
MM slash DD slash YYYY
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:
- VISA
- MC
- AMEX
- DISCOVER
- CARE CREDIT (6-Month Term)
Cardholder Name:
Card Number:
Expiration Date:
CVV:
Cardholder Signature:
Billing Zip Code:
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. $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.
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.

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:
Last Name:*
First Name:*
Date of Birth:*
MM slash DD slash YYYY
Age:*
Height:*
Weight:*
Gender:*
- Male
- Female
Current General Health Status:*
- Excellent
- Good
- Fair
- Poor
Responsible Party:*
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 Heart Problem*
- NO
- YES
WHEN
MEDICINE/TREATMENT
LUNG DISEASES:
Wheezing/Bronchiolitis*
- NO
- YES
WHEN
MEDICINE/TREATMENT
Asthma*
- NO
- YES
WHEN
MEDICINE/TREATMENT
Pneumonia*
- NO
- YES
WHEN
MEDICINE/TREATMENT
Obstructive Sleep Apnea*
- 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*
MM slash DD slash YYYY
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.
CONSENT for (Patient Name):*
Relationship to Patient:*
Patient's/Legal Guardian Signature:*
Date*
MM slash DD slash YYYY
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