Who may we thank for referring you?
Does your child have any allergies/ reactions to the following: antibiotics,
anesthetics, medications, latex,foods or other substances?
Useful Phrases, Words, Or Actions That Work Best With Your Child Or Any
Additional Information That May Help Us To Prepare For a Sucessful Dental
To the best of my knowledge, all of the preceding answers are true and
correct. IF the patient has a change in health or medicines, NY Pediatric
Dentistry will be informed. The parent/ legal guardian whose signature
appears, consents to treatment as explained by our office and is responsible
for all fees at the time of services rendered, if we are not an in‐network
provider for your insurance. Claims will be electronically forwarded at
the time of visit so reimbursement can be promptly made.
INSURANCE is a contract between an employer and a dental insurance company.
Benefits received are based on the terms of the contract that was negotiated
between the employer and that insurance company, not NY Pediatric Dentistry.
If we are a provider for your insurance, we will do everything possible
to make the most of your benefits so that out of pocket costs are limited.
Please be aware that ultimately the responsibility of any expenses after
insurance reimbursement to us lies with you. Many policies provide only
basic coverage for dental services. Benefits occasionally do not cover
those services necessary to achieve a high quality, safe result, especially
in pediatric dentistry. By signing below you understand the above explanations
regarding the possible limitations of your policy and will be familiar
with it coverage prior to treatment.
I understand that under the Health Insurance Portability and Accountability
Act of 1998 (HIPAA), I have certain rights to privacy regarding my protected
health information. I have received (available on our website or at front
desk), read and understand the Notice of Privacy Practices containing a
more complete description of uses and disclosures of my health information.
I understand that NY Pediatric Dentistry has the right to change its Notice
of Privacy Practices from time to time and that I may contact them at any
time to obtain a current copy of the Notice of Privacy Practices. I understand
that I may request in writing how my private information is used or disclosed
to carry out treatment, payment or health care operations.
I grant NY Pediatric and Adult Dentistry permission to contact previous
dental practitioners for records/ radiographs as part of treatment for
my child’s oral health care.
Click on the hyperlink to read or obtain a copy of our Notice of Privacy
I have read the information regarding the secured uploading of patient
information to the NY Pediatric Dentistry web site, and grant the permission
to securely upload my information. If needed, a copy of the Consent for
Internet Communication or Notice of Privacy Practices will be provided
by the office or it is always available on the website.