Rebecca Falsafi DDS, MS
3D Orthodontics and Orthopedics for Children and Adults
6161 Transit Rd., Suite 10
East Amherst, NY 14051
CONE BEAM CT SCAN
i-CAT® CBCT INFORMED CONSENT
As of 2.26.10
About i-CAT® CBCT Cone Beam Scans
- About ½ as much as a full series of orthodontic digital images
- About 1/5 as much as a full mouth series of standard dental x-rays (28 films)
- About 1/70 as much as a typical medical CT scan
HIPAA/Record Release Consent Form
- Protected health information may be disclosed or used for treatment, payment, or healthcare operations and potentially anonymous usage in a publication.
- The patient has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
- The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
Medicaid Insurance Coordinator Letter
Dear Parent and New Patient,
My name is Trenay. I am the Insurance Coordinator for Dr. Falsafi’s office. As you begin your orthodontic venture with our office, my job is to help you maximize your insurance benefits during the entire course of treatment to allow our office to be fully compensated by the state for your orthodontic treatment.
To make the billing process as smooth as possible. I will need you to please:
Notify me Immediately of ANY insurance changes.
- Medicaid & Managed Care Plans requires a prior authorization in order to continue to pay for orthodontic treatment, therefore, if your plan changes, you will require a new authorization.
- Do NOT wait until the next appointment. Waiting may cause delays in obtaining approvals and you may not be approved for your appointment.
Speak with me directly.
- I will personally submit all required information to your insurance company. I prefer to receive all new insurance information directly from you. If I am not in the office, there is a form to complete and I will call you with any questions.
Keep all scheduled appointment.
- Regularly missing appointments does not only delay treatment, but it can affect your insurance billing and approvals.
If new insurance information is not received in a timely manner, you will become responsible for any missed payments.
If you lose your Medicaid Coverage:
- Please call me. (You have options, Let’s discuss them)
- Keep your scheduled appointment. (Do NOT miss or cancel your scheduled appointment.)
Communication is key. You/your child has an orthodontic medical device in your mouth, do not let it go untreated due to insurance coverage. Let’s talk.
I am here to help, please feel free to contact me with any insurance questions or concerns you may have.
Welcome to the office.
Medicaid Financial Agreement
is starting orthodontic treatment in the office of Dr.Rebecca Falsafi under the New York
State Medicaid Program. New York State has approved orthodontic treatment for my child, and I understand that this treatment will be fully covered by New York State as long as my child remains eligible and is compliant to the Medicaid guidelines.
If I should lose my Medicaid benefits, or be dismissed from the Medicaid Program due to non-compliance, I agree to pay the remaining account balance to complete treatment or sign a waiver and request the removal of all orthodontic appliances at No Additional Cost.
Our discounted Medicaid orthodontic treatment fee is estimate of $6,000.00.
Payment is being funded by the New York State Health Department. If for any reason state funds are discontinued, I understand that I become fully responsible for the remaining balance of the payment.
*Your treatment fee will be evaluated depending on where you are in treatment.
The Medicaid Coordinator for Dr. Rebecca Falsafi has reviewed this form with me and I fully understand the contents and take full responsibility for my account.
Medicaid Orthodontic Compliance Agreement
- Comply with necessary instructions for home care (wearing elastics, headgear, removable appliance, etc.)
- Keep multiple appointments over several years;
- Maintain an oral hygiene regimen;
- Be cooperative and complete all needed preventive, oral surgery and treatment visits.
If it is determined that the recipient is exhibiting non-compliant behavior such as:
- Multiple missed orthodontic, oral surgery procedure appointments and general dental appointments.
- Continued poor oral hygiene, and/or failure to maintain the appliances and/or untreated dental disease.
A letter must be sent to the parent/guardian that documents the factors of concern and the corrective actions needed and that failure to comply can result in discontinuation of treatment.
If orthodontic treatment is discontinued for cause, the parent/guardian
and/or recipient must receive and sign a statement that they understand that treatment is being discontinued prior to completion; the reason(s) for discontinuation of treatment must be included; and, that it may jeopardize their ability to have further orthodontic treatment provided through the NYS Medicaid Program.
Do not risk your orthodontic benefits with non-compliance. Please help us to complete your orthodontic treatment by following these rules and guidelines.
The Medicaid Coordinator for Dr. Rebecca Falsafi’s office has reviewed this form with me and I fully understand the contents.