Children's Dental Center of Madison, S.C.

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Fitchburg
E. Madison
W. Madison
Sun Prairie

Fitchburg:
(608) 288-1543

East Madison:
(608) 825-7500

West Madison:
(608) 833-6545

Sun Prairie:
(608) 453-5600

Referral

Financial/Insurance Form

New Patient Financial/Insurance Form

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Tell Us About Your Child/Children

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Parent or Legal Guardian's Information

The information in this section applies to to the main legal caregiver of the child / children.
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Marital Status(Required)
Address(Required)

Spouse or Other Legal Guardian's Information

(if different from #2 above)
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Marital Status
Address

How Did You Learn About Our Practice

Who Will Be Accompanying The Child/Children To Their Appointment?

Important Note: The parent or guardian who accompanies the child is legally responsible for payment at the time of service.
Do you have legal custody of the child?(Required)

Person Responsible For Account

Billing Address(Required)

Emergency Contact Information

Primary Dental Insurance

Insurance Address(Required)
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Dual (Secondary) Insurance

Do you have dual (secondary) insurance?
Insurance Address
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HIPAA Consent

I have been informed by your office of your Notice of Privacy Practices with a complete description of the uses and disclosures of my health information. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action on this consent rendered. I have read the above information and understand my obligations.

Financial Policy

Payment is due when services are rendered. We accept cash, personal checks, and all major credit cards. We realize that some procedures are more extensive than others and we will be more than willing to work out alternative financial arrangements prior to treatment. I understand and agree that, (regardless of my insurance status or marital status), I am ultimately responsible for the balance on this account for any professional services.

I understand that the information I have given is correct to the best of my knowledge and that it is my responsibility to inform this office of any changes.

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Children's Dental Center Financial Relationship

Thank you for choosing Children's Dental Center to serve your family's dental needs. Our office is dedicated to providing the highest quality of dental care possible for every patient. The following is a statement of our financial relationship with all of our families. Please review and let us know if you have any questions.

For your convenience we accept cash, personal checks, debit cards, all major credit cards, and Care Credit financing. You are welcome to use your Flex Spending or Health Savings Account, as applicable.

Non-Insured Patients: I understand that if I DO NOT have insurance coverage I select to be self-pay. Payment is due on the day that dental services are performed. A 5% discount is given when the full amount due is paid using a check or cash payment on the day of service.

Insured Patients: I understand that if I DO HAVE dental insurance, Children's Dental Center will file my insurance as a courtesy. There is no guarantee of coverage. Patient portions are an estimate and not a guarantee of exact payment. The patient is responsible for the estimated portion of the procedures and deductibles at the time of service. Once your insurance company has paid, you will be responsible for any balance that is remaining. If your insurance policy pays you directly, you are responsible for the amount they pay and your portion.

I understand that my insurance can be OUT OF NETWORK with my chosen provider. Procedures are quoted at standard fees and I am provided with an estimate of my out of pocket portion according to my insurance policy. This is not a guarantee of benefits and I accept responsibility for payment of services.

I understand that my insurance can be IN NETWORK but the benefits may not cover all services according to the estimate given. I am responsible for the deductible and my patient portion at the time services are rendered and any remaining balance after my insurance has paid.

Please understand that insurance is a contract between you (your employer) and your insurance company. If an insurance carrier has not paid us within 60 days of billing, any unpaid professional fees are due and payable in full from you.

All ESTIMATED fees are due at the time of service.

Payment Plan Options:

Third party financing through Care Credit is a form of payment we accept. They offer flexible financing options with more information at carecredit.com. We are happy to help you with the process.

Credit Card authorization for recurring charges is available when the treatment estimate exceeds $350 and your account remains in good standing with previous payments due. The services need to be paid in full in a total of four months or less. Any payment arrangements need to be worked out with our billing coordinator prior to the appointment.

I have read, understand and agree to all of the above. I have been given the opportunity to ask questions. If I have insurance, I hereby authorize my insurance company to pay my dental benefits directly to Children's Dental Center, and by signing the Health History, I authorize Children's Dental Center to release any medical information to my insurance company as needed to process my claim(s).

This statement has been edited to fit Children's Dental Center's needs and this document was not created by them.

Consent(Required)