Hiremath Paperwork Form

Patient Name

Date:

As a courtesy, Hiremath Orthodontics will file a claim for your orthodontic insurance benefits. The amount estimated to be paid by your insurance company will be placed on an insurance ledger. When a payment is received, it will be credited to the insurance ledger. (Patient payments will be credited to your patient ledger.) Payments will be made according to the insurance company’s policies. Many insurance companies pay a placement fee, followed by monthly or quarterly payments over the estimated length of treatment. Most insurance companies do not pay the entire benefit in a lump sum at the beginning of treatment.

This contract is the total allowable fee provided by your insurance company. The contracted amount may reflect a managed care/insurance discount.

My signature authorizes this office to file my claim(s) and assigns to this office all rights, title, and interest to my orthodontic reimbursement benefits under the patient's insurance policy. I understand that my signature also allows this office to release information regarding my visits to the patient's insurance carrier. If regular orthodontic appointments are not kept by the patient, we cannot continue to accept payment from the insurance company. The insurance company will be notified that the patient is “inactive” and the insurance payments will be stopped.

I understand that I am responsible for any portion of the total estimated insurance benefit that is not paid by my insurance carrier.

If my insurance does not cover orthodontic benefits or is cancelled/deleted for any reason, I understand that I am responsible for the entire case fee.

If there are changes to my orthodontic insurance benefits, I will notify Hiremath Orthodontics.

If Hiremath Orthodontics receives an Explanation of Benefits (EOB) from my insurance carrier notifying them that my benefits have been terminated, I understand that any amount remaining on the insurance ledger will be moved to the patient ledger and become my responsibility.

DUAL INSURANCE If a patient is covered by two orthodontic insurance plans, Hiremath Orthodontics will file claims for both policies. We can expect the primary carrier to pay the estimated benefit. It is our experience, however, that the amount which will be paid by the secondary insurance cannot be accurately estimated. Most secondary benefit plans do not pay the entire lifetime benefit.

Because we cannot accurately estimate the amount that will be paid by the secondary carrier, no money is placed on the secondary insurance ledger. When a payment is received from the secondary insurance, it will be credited to the responsible party's overall contract balance, thereby reducing the number of payments. Payments by the responsible party are due monthly regardless of payment received by the secondary insurance.

Responsible Party Signature

Date:

Hiremath Orthodontics

Dr. Kumar Hiremath

We.will give you a reason to smile

ORTHODONTIC LETTER OF INFORMATION AND consent AGREEMENT

As a rule, excellent orthodontic results can be achieved with informed and cooperative patients. Thus, the following information is routinely supplied to anyone considering orthodontic treatment. Like any treatment of the body there are hazards, inconveniences and limitations. These seldom outweigh the long-range benefits, but should be considered in making the decision to wear orthodontic appliances.
Perfection is always our goal. The orthodontist will use his/her knowledge, training, skill and experience to. achieve perfect function that is also esthetically pleasing, but much depends on the patient's growth patterns, genetics, oral health and cooperation.
Throughout life, tooth positions are constantly changing. This is true with all individuals regardless of whether they have worn braces or not. After orthodontic treatment, patients are subject to the same subtle changes that occur in non-orthodontic patients. In the late teens or early twenties, orthodontic patients may notice slight irregularities developing in their front teeth. This is particularly true if their teeth were extremely crowded prior to treatment. Prolonged wearing of a retainer may be the only way to prevent this if it becomes undesirable.
Decalcification (permanent markings on the teeth), tooth decay, or gum disease can occur if patients do not brush and floss their teeth properly and thoroughly. Excellent oral hygiene and daily plaque removal are musts. Sugars and between meal snacks should be eliminated. Regular check-ups (every 6 months) with the family dentist are necessary to check for decay and cleaning of the teeth.
Cold sores, Canker sores and irritation or injury to the mouth are possible while wearing braces. Allergic reactions to dental material or medication are rare, but do occur occasionally. There may be a need for extraction of teeth, fillings, crowns, bridges, gum treatment or other dental procedures before, during or after orthodontic treatment. If necessary, this will be done by another dendist.
On rare occasions, the nerve of a tooth may become damaged. A tooth that has been irritated by a deep filling or even a minor blow may require treatment by another dentist.
in some instances the root ends of the teeth are shortened during treatment. This is called root resorption. Under healthy circumstances, the shortened roots are no disadvantage. There is no way to foresee whether this will happen and nothing can be done to prevent this from occurring.
There Is also a chance that pain and/or dysfunction may occur in the jaw Joints (1 Mj or IMD). 100th alignment or bite correction can usually improve teeth-related causes of jaw discomfort, but additional treatment by another dentist may be required.
Orthodontic treatment can succeed only through the joint cooperation of all parties involved. Together we can achieve the best possible result. In many instances, lack of cooperation in the requested use of headgear, elastics and retainers will make a successful completion of treatment impossible or lengthen the duration of treatment. We appreciate your confidence in selecting our office. We want you to be fully informed, so ask questions anytime. During the period of treatment we will make models, x-rays, and photographs as needed which may be used for professional reference and display in orthodontic journals, books, meetings and patient education.

I have read and understand this letter of information and with this knowledge consent to treatment.

Patient Name

Signature (patient or Responsible Party)

Date:

151 Ridge Point Parkway Suite #100
Keller, Texas 76248
817-697-5166
Braces@hiremathortho.com
www.hiremathortho.com

Acknowledgment of Receipt of Notice of Privacy Practices and HIPAA Non-Secure Communication Consent Form

Patient Name:

Date of Birth:

This consent form allows Hiremath Orthodontics to use and disclose information about me provecred Mller Health Insurance Portability and Accountability Act of 1996. This information may be used or disclosed to carry out treatment, payment or health care operations.

Hiremath Orthodontics has provided me with a Notice of Privacy Practices, which more completely describes such uses and disclosures. It provided this notice prior to my signing this form in accordance with my right to review its practices before signing consent.

I understand that the terms of the Notice of Privacy Practices may change and that I may obtain revised notices by contacting the Privacy Officer at Hiremath Orthodontics.

I hereby authorize Hiremath Orthodontics to use unsecured email and mobile phone text messaging to transmit to me the following protected health information: 1) Information related to the scheduling of Initial appointments; and, 2) Information related to billing and payment.

I hereby authorize that Hiremath Orthodontics may leave messages on my voicemail to confirm appointments, and/or may speak with other members of my household and leave messages with them regarding my Initial appointments.

Home Phone

Office Phone

I hereby authorize that Hiremath Orthodontics may disclose my health information to any person(s) who accompany me to my appointment, and are present with me in the office while I meet with my dentist and Initial staff.

I hereby authorize that Hiremath Orthodontics may disclose my personal health information to the person who Initial I have listed as my emergency contact.

Thereby authorize that Hiremath Orthodontics may disclose my personal health information to the following

Name

Telephone Number

Relationship to Patient

Furthermore, my (or my child’s) personal health information may NOT be disclosed to the foZowing person(s)

Name

Telephone Number

Relationship to Patient

I understand that at any time I have the right to revoke this consent provided that I do so in writing, but that Hiremath Orthodontics services may still use information to complete any actions that it began prior to my revoking consent and which rely on my protected health information. | understand that Hiremath Orthodontics may refuse service if I revoke this consent.

I understand that I have the right to request - now and in the future — how protected health information is used or disclosed to carry out treatment, payment and health care operations, and must be provided by me in writing. I understand that while Hiremath Orthodontics is not required to agree to my requested restrictions, if it does agree, it is bound by that agreement.

By my signature below, I affirm the above information.

Signature of Patient

Date

Signature of Parent (if minor) / Authorized Representative

Date

Consent for Photography

Hiremath Orthodontics

Patient Name:

DOB:

Parent or Legal Guardian:

I consent to have my (or child or an individual to whom I provide guardianship) image to be taken by the staff at Hiremath Orthodontics as described below.

I understand that my (or child or an individual to whom I provide guardianship) photographs, videotapes, digital, and other images may be recorded to document and assist with my care and the payment of my bill (or child or an individual to whom I provide guardianship). These images may be used to assist in the education of students and residents within the institution. | understand that Hiremath Orthodontics will own these images, but that I will be allowed access to view them or to obtain copies of them at a reasonable cost. Other than for treatment, education, and payment purposes, images that identify me (or child or an individual to whom I provide guardianship) will be released and/or used outside the organization only upon written authorization from me or the patient representative.

If the images are to be taken for any purpose other than for treatment, education, or payment purposes, the purpose(s) must be stated:

I may revoke or withdraw this consent at any time. Such withdrawal of consent must be made in writing. Withdrawal of consent does not affect any information disclosed prior to the written notice of withdrawal.

I release and hold harmless Hiremath Orthodontics, its staff and employees from any and all claims or causes of action that may have of any nature whatsoever, which may in any manner result from the use of the photograph or other image.

By signing below, I am indicating that I have read and understand the “Consent for Photography” form. I am either the patient or have the authority to give consent for the patient. My questions regarding this consent have been answered.

Patient or Patient Representative Signature

Date

If Patient Representative, Relationship to Patient

Printed Name

Hiremath Orthodontics

Office Policies

Missed Appointments

Appointments are scheduled based on something called “Doctor Time”. This basically means that it has been determined, based on the type of appointment, how much time is required by the orthodontist and how much time is required by the orthodontic assistant to take care of the patient’s needs. Even though each chair is filled, the orthodontist is never scheduled to be in two places at the same time. We are often asked if we can squeeze someone in but this does not work because an unscheduled patient that is squeezed into the schedule will cause a traffic jam which would result in someone else waiting 15-30 minutes for their scheduled appointment.

For this reason, should you miss an appointment, unless we have an opening due to a cancellation, it could be as long as 4-5 weeks before another appointment will be available. If you need to be seen sooner than this, we can usually make arrangements to see you during school hours when we do not see as many patients. Also, should you leave our office without making an appointment, we may not have an opening during the time frame that the doctor wanted to see the patient. As you can see, missed appointments can result in prolonging the patient’s treatment.

Tardiness

Our office strives to see all of our patients at their appointed times. Sometimes, we fall behind for no obvious reasons. Sometimes a parent requires additional time for explanation or a patient requires additional tooth brushing instructions. We try not to let anyone leave our office with any unanswered questions and we also want to make sure that the patients are doing a proper job of taking care of their teeth. We have worked these circumstances into our schedule so that the schedule can stay fairly close to being on time.

If a patient arrives 15min or later for an apt, it may not be possible to see them. Our appointments are scheduled on 15 and 30 minute intervals and seeing a late patient would mean that someone else that has arrived on time could not be seen at their appointed time. If seeing a late patient results in other patients being seen late, the appointment will have be rescheduled. Of course, if there is any | possibility of seeing the patient, we will. We do not want to inconvenience anyone. If you think that you are going to be late, give us a call and we will see what we can do for you.

Broken Brackets

Broken appliances are a part of orthodontic treatment. It goes with the territory. Sometimes the patient has received trauma to the mouth or maybe they just decided that it would not hurt to cheat a little on the “No Eats List”. Sometimes brackets will come loose while the patient is just. sitting around, but this only happens if the brace has already been somewhat loosened at an earlier date but did not fully break free from the tooth.

We understand and do not get upset about it. But, we do want you to know that broken brackets will result in a delay in treatment. We also want you to know that any appointment that involves the placement of braces must be done during school hours. This is a long appointment which cannot be done before or after school because everyone wants to be seen at this time.

Also, we let the patients know that the first 5 broken braces are on us. After that, there will be a $25.00 charge for each additional broken bracket. We will let them know each time a bracket is broken and how many more freebies they have before THEY have to pay for the appointment. It is amazing how quickly the breakage stops once they start paying for it. Broken brackets are also the number one reason we fall behind in our schedule, so please call ahead to let us know if one of your brackets is broken so we can work the repair into our schedule.

Dental Visits and Cleanings

Our office will not be checking for cavities during the patient’s visit to our office unless it is very obvious without the use of x-rays. This is why it is important that the patient see their dentist every 4-6 months for cleanings and check-ups. We will try to keep track of these appointments for you but if you have canceled or missed an appointment with your dentist, it will throw our tracking system out of whack.

Some dental offices ask that the patients present to their office with the orthodontic wires removed so that the hygienist can do a better job of working around the braces. Some offices have special equipment that does not require that the wires be removed. If your dentist requests that the wires be removed, we will need to make arrangements with you for the patient to be seen in our office before and after the cleaning appointment.

This does not all have to happen in the same day. The wires can be removed one afternoon and replaced the next afternoon following the cleaning appointment. We will try to make it as convenient for you as we possibly can. Also, we need to know at least 6 weeks in advance so that we can coordinate and schedule the appropriate appointments.

Please let us know if there is anything we can do to improve your time spent with us!

Signature

Date

INSURANCE ADDENDUM TO ORTHODONTIC TREATMENT CONTRACT

Hiremath Orthodontics

Dr. Kumar Hiremath

We.will give you a reason to smile

ORTHODONTIC LETTER OF INFORMATION AND consent AGREEMENT

Hiremath Orthodontics

Medical History

Hiremath Orthodontics

Dental History

Acknowledgment of Receipt of Notice of Privacy Practices and HIPAA Non-Secure Communication Consent Form

Consent for Photography

Hiremath Orthodontics

Hiremath Orthodontics

Office Policies

Missed Appointments

Tardiness

Broken Brackets

Dental Visits and Cleanings