Child's Information

Does child go by another name?
First Name Last Name Weight
more items

Child's Home Address

Mother's Information

Mother's Information

Mother's relationship to child
Mother Employed

Mother's Address

is mother's address same as child's
Father's Information

Father's Information

Father's relationship to child
Father Employed

Father's Address

is father's address same as child's
Who is accompanying the child today
Select all preferred method of communications

Person Responsible for Account

Billing Address

Is there insurance

First Insurance Information

Policy Owner's relationship to child
Is there other insurance information

Second Insurance Information

Same Policy Owner as Previous

Second Insur. Policy Owner

Policy Owner's relationship to child
Is there other insurance information

Third Insurance Information

Same Policy Owner as Previous

Third Insur. Policy Owner

Policy Owner's relationship to child

BILLING, FINANCIAL, & OFFICE POLICIES

Treatment

The type of treatment you receive from Children’s Dentistry of Longwood, PSC is based upon our professional dental judgement, and NOT on whether the procedure is covered by your Dental Insurance Benefit Plan.

Dental Insurance

Our office is happy to file claims with your dental insurance carrier. However, since the terms of your coverage is a contract between you and your insurance carrier, questions, problems, or disputes about your insurance coverage need to be addressed directly to your insurance company. We submit insurance as a courtesy for you and your family. For all non-dental insurance claims, patients must pay in full upfront and will be reimbursed by their non-dental insurance if it applies. Ultimately, the fee and payment is the patient responsibility. It is the patient’s responsibility to confirm with your dental insurance company that David E. Donald, D.D.S. is an “in-network” or “out-of-network” provider prior to being seen. In most cases we would be considered an out of network provider or in some cases a PPO provider. The patient is responsible for all charges not covered by their insurance policy.
It is your (the patient’s) responsibility to know what your insurance coverage and limitations regardless if your insurance coverage is “In or Out of network”, which includes examinations, x-rays, and treatment of any kind. Payment of your copay, deductibles, estimated amount not covered by your dental insurance is due at the time services are rendered. Any amount not covered by your insurance or denial of coverage for any reason by your insurance coverage, or patient refusal to return to this office within 30 days to complete a procedure previously started, such as (but not limited to) laboratory procedures, becomes the patient’s responsibility and payment is due immediately with no grace period. Children’s Dentistry of Longwood reserves the right to ask for and expect payment in full with no grace period at any time, even prior to submitting dental claims to the patient’s dental insurance.

Disputes With your Insurance Company

If you have a dispute with your insurance company (Dental or other) over coverage, that dispute must be resolved between you and your insurance company. The amount owed to David E. Donald D.D.S. during the duration of your dispute is your responsibility and payment is due immediately in full, with no grace period.

Dental Pre-Authorizations

Dental Pre-Authorizations for treatment are submitted in writing upon patient request. Pre-authorizations must be sent with up-to-date diagnostic x-rays, along with all necessary insurance, personal, dental and/or medical information. This can take up to 90 days if not 120 days. This is time from is from your insurance company. If you don’t wait for your pre-authorization response before beginning treatment, you are still responsible for any amount not covered by your insurance for any examinations, x-rays and/or treatment. We recommend that you get your pre-authorization response back prior to starting treatment if you are needing to know the exact dollar amount of how much your potion will be.

Laboratory Cases

The day any laboratory procedure (such as but not limited to Space Maintainers) is started, your estimated portion is due in full the day of the first appointment or impression. If insurance denies or covers less than the estimated portion you will be billed for the remaining costs and payment is due immediately with no grace period.

Change of Personal Information

It is your responsibility to notify us, in writing, of any changes in your address, phone number, employment information, school status, insurance coverage and etc. so that you may maximize your insurance benefit. We have online forms to easily update your information at your covenance. Monthly statements are mailed out as a courtesy when there is any remaining portion after insurance has paid, otherwise all balances are due day of treatment.

Family Balance

All balances must be paid in full in order to proceed with future treatment. Guarantors (the patient or guardians) are responsible for any and all (but not limited to) collection agency recovery fees, attorney fees and/or legal fees, court costs, interest on delinquent accounts, as well as the time the doctor and/or staff spends working on (but not limited to) filing paperwork, appear for court, mediation/proceedings/and/or legal meetings and/or frivolous legal charges. There is a $45.00 charge on all returned checks (per check). At 120 days past due your account may be turned over to our collection agency, court and/or attorney. All of the above stated responsibilities of the patient are due immediately without a grace period. If David E. Donald, D.D.S. is notified as being included in any bankruptcy files, the patient and/or immediate family members will be dismissed as patients of David E. Donald, D.D.S. for failure to meet patient financial obligations to David E. Donald, D.D.S.

Financing

David E. Donald, D.D.S. does not offer in house financing, Care Credit or payment plans. All fees are due at time of service unless expecting insurance to cover. Once all insurance payments or denials have been processed, the balance is due at that time.

Nitrous Oxide/Oxygen

Nitrous Oxide is usually not covered by insurance. It is the guarantor’s responsibility to pay for nitrous regardless if Nitrous Oxide is deemed necessary by the doctor or if requested by the patient to ease anxiety during dental procedures.

Copies of Dental Records

Florida State Law mandates that the patient or designated representative is entitled to 1 (one) coy of his/her dental Record’s at no charge. If more than one is needed a fee may apply.

BILLING, FINANCIAL, & OFFICE policies
Dr. David Donald, D.D.S.

TREATMENT: The type of treatment you receive from Children’s Dentistry of Longwood, PSC is based upon our professional dental judgement, and NOT on whether the procedure is covered by your Dental Insurance Benefit Plan. 
DENTAL INSURANCE:  Our office is happy to file claims with your dental insurance carrier. However, since the terms of your coverage is a contract between YOU & YOUR INSURANCE CARIER, questions, problems, or disputes about your insurance coverage need to be addressed directly to your insurance company. We submit insurance as a curtesy for you and your family. For all non-dental insurance claims, patients must pay in full upfront and will be reimbursed by their non-dental insurance if it applies. Ultimately, the fee and payment is the patient responsibility. It is the patient’s responsibility to confirm with your dental insurance company that David E. Donald, D.D.S. is an “in-network” or “out-of-network” provider prior to being seen. In most cases we would be consider an out of network provider or in some cases a PPO provider. The patient is responsible for all charges not covered by their insurance policy. 
It is YOUR (the patient’s) responsibility to know what your insurance coverage and limitations regardless if your insurance coverage is “In or Out of network”, which includes examinations, x-rays, and treatment of any kind. Payment of your copay, deductibles, estimated amount not covered by your dental insurance is due at the time services are rendered. Any amount not covered by your insurance or denial of coverage for any reason by your insurance coverage, or patient refusal to return to this office within 30 days to complete a procedure previously started, such as (but not limited to) laboratory procedures, becomes the patient’s responsibility and payment is due immediately with no grace period. Children’s Dentistry of Longwood reserves the right to ask for and expect payment in full with no grace period at any time, even prior to submitting dental claims to the patient’s dental insurance. 
Disputes With your Insurance Company: If you have a dispute with your insurance company (Dental or other) over coverage, that dispute must be resolved between you and your insurance company. The amount owed to David E. Donald D.D.S. during the duration of your dispute is your responsibility and payment is due immediately in full, with no grace period. 
Dental Pre-Authorizations: Dental Pre-Authorizations for treatment are submitted in writing upon patient request. Pre-authorizations must be sent with up-to-date diagnostic x-rays, along with all necessary insurance, personal, dental and/or medical information. This can take up to 90 days if not 120 days. This is time from is from your insurance company. If you don’t wait for your pre-authorization response before beginning treatment, you are still responsible for any amount not covered by your insurance for any examinations, x-rays and/or treatment. We recommend that you get your pre-authorization response back prior to starting treatment if you are needing to know the exact dollar amount of how much your potion will be. 
Laboratory Cases: The day any laboratory procedure (such as but not limited to Space Maintainers) is started, your estimated portion is due in full the day of the first appointment or impression. If insurance denies or covers less than the estimated portion you will be billed for the remaining costs and payment is due immediately with no grace period.
Change of Personal Information: It is your responsibility to notify us, in writing, of any changes in your address, phone number, employment information, school status, insurance coverage and etc. so that you may maximize your insurance benefit. Monthly statements are mailed out as a courtesy when there is any remaining portion after insurance has paid, otherwise all balances are due day of treatment. 
Family Balance: All balances must be paid in full in order to proceed with future treatment. Guarantors (the patient or guardians) are responsible for any and all (but not limited to) collection agency recovery fees, attorney fees and/or legal fees, court costs, interest on delinquent accounts, as well as the time the doctor and/or staff spends working on (but not limited to) filing paperwork, appear for court, mediation/proceedings/and/or legal meetings and/or frivolous legal charges. There is a $45.00 charge on all returned checks (per check). At 120 days past due your account may be turned over to our collection agency, court and/or attorney. All of the above stated responsibilities of the patient are due immediately without a grace period. If David E. Donald, D.D.S. is notified as being included in any bankruptcy files, the patient and/or immediate family members will be dismissed as patients of David E. Donald, D.D.S. for failure to meet patient financial obligations to David E. Donald, D.D.S. 
Financing: David E. Donald, D.D.S. does not offer in house financing, Care Credit or payment plans. All fees are due at time of service unless expecting insurance to cover. Once all insurance payments or denials have been processed, the balance is due at that time. 
Nitrous Oxide/Oxygen: Nitrous Oxide is usually not covered by insurance. It is the guarantor’s responsibility to pay for nitrous regardless if Nitrous Oxide is deemed necessary by the doctor or if requested by the patient to ease anxiety during dental procedures. 
Copies of Dental Records: Florida State Law mandates that the patient or designated representative is entitled to 1 (one) coy of his/her dental Record’s at no charge. If more than one is needed a fee may apply. 


By my signature blow, I certify that I have read, understand, accept and agree with as well as agree to adhere to all of the above mentioned policies and understand all of my responsibilities set forth as stated above.
Sign above

Child's Dental History

Does your child have any of the following?
Lip Sucking/Biting
Nail Biting
Nursing/Bottle Habits
Thumb/Finger Sucking
Child's first visit to the dentist?
Were X-Rays taken?
by who?
Does family have a general dentist?
General Dentist
Has the child ever had a serious / difficult problem with previous dental work?
Have there been any injuries to the teeth, face, or mouth?
Is the child’s water fluoridated?
Does the child take fluoride supplements?
Has the child ever had any pain or tenderness in their jaw/joint (TMJ/TMD)?
Does the child brush his/her teeth daily?
Does the child floss his/her teeth daily?

Child's Medical History

Is the child currently under the care of a physician?
Does child have any allergies to any drugs?
Please describe the child’s current physical health?
Does the child have any of the following?
Yes No

Authorization for Care

Our Office is committed to meeting or exceeding the standards and mandated put forth by O.S.H.A., C.D.C., H.I.P.A.A., and the A.D.A.

I authorize Children’s Dentistry of Longwood and their staff to perform the necessary dental services my child may need.

I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child’s medical status.

Authorization for Care

Dr. David Donald, D.D.S.
Our Office is committed to meeting or exceeding the standards and mandated put forth by O.S.H.A., C.D.C., H.I.P.A.A., and the A.D.A.
I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child’s medical status.
I authorize Children’s Dentistry of Longwood and their staff to perform the necessarydental services my child may need.

Sign above
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