I, the undersigned certify that I (or my dependent) have insurance coverage with the insurance company stated above and assign payment directly to doctor. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
I request and authorize Dr. Hirano, or any other doctor at Kidz Dental Care, to examine, clean, and provide dental treatment on my child's teeth. I further request and authorize the taking of dental x-rays as may be considered necessary by Dr. Hirano / Staff to diagnose and/or treat my child's dental problem. I will allow photographs to be taken of my child or child's teeth for diagnostic, educational, or marketing purposes. I understand that dental treatment for children includes efforts to guide their behavior by helping them understand the treatment in terms appropriate for their age. Dr. Hirano / Staff will provide an environment likely to help children learn to cooperate during treatment by using praise, explanation and demonstration of procedures and instruments, using variable voice tone and stabilization with a pedowrap. I will be responsible for any charges incurred on this child for dental treatment.
I understand that collection actions may be taken if my balance goes beyond 90 days.
I consent to the use and disclosure of my protected health information to obtain payment information in connection with my dental claims.