Patient Paperwork

For your convenience, we are happy to provide you with downloadable patient forms to make your child’s first appointment more timely.  Please print the forms and bring the completed information with you to your appointment.

Patient Paperwork PDF

Office Policies

First Visit Information

As a pediatric dental clinic, we cater to the unique needs of our patients. If your child has developmental or behavioral issues that may affect his or her ability to accept dental treatment in a clinical setting, please inform us when making appointments. If we are aware of a child’s particular needs, we will make every effort to accommodate them. Please remember that our goal is to become your child’s “dental home” and provide your child with comprehensive dental health care. Understanding your child’s unique needs allows us to provide better care.

Parental Involvement

We encourage parents to stay with their children during all visits to our office. We ask that parents be “passive observers” during the dental visit, only participating when prompted by the dentist or team member. On rare occasions, a parent may be asked to step out of the room, in order to encourage the uncooperative or apprehensive child to develop coping skills and trust in the members of our dental team.


We attempt to schedule appointments at your convenience and when time is available. Preschool children should be seen in the morning because they tend to be more cooperative.   School children requiring multiple appointments to restore their oral health should also be seen in the morning for the same reason.

Since appointed times are reserved exclusively for each patient, we ask that you please notify our office 24 hours in advance of your scheduled appointment time if you are unable to keep your appointment. Another patient who needs our care could be scheduled if we have sufficient time to notify them. We realize that emergencies occur, and we ask for your assistance in this regard. If you do not call to cancel and fail to show as scheduled, you may be charged a broken appointment fee of $50.00. If your child misses three (3) consecutive appointments, we may request that you seek dental care at another office that can better accommodate your schedule.


If for any reason you decide to leave our practice, you have the right to request copies of your dental records/x-rays. Depending upon chart size and format of the record duplication’s, a fee of up to $25.00 may be applied.  We will make every attempt to have record duplication requests completed within 24 hours of the request.

Insurance Claims

We file dental insurance as a courtesy to our patients. We do not have a contract with your insurance company; only you do. Therefore, we are not responsible for how your insurance company handles its claims or for what benefits they pay on a claim. We will assist you in estimating your portion of the cost of treatment, but we cannot guarantee what your insurance will or will not cover for each claim. Although we make every attempt to file claims accurately and to resolve errors if they occur, we cannot be responsible for any errors in filing your claims.

Changes since January of 2014, the Affordable Care Act (ACA) and Pediatric Dental Plans
Since the change in healthcare plans and coverage in January 2014 there have been significant changes and many consumers are confused about these changes. Our office understands how all these plans work. If you have a pediatric dental plan embedded into your medical plan, we can let you know how this works before you come into our office. Some of these embedded plans actually cover services in our office. Others cover nothing. To find out how your plan works, simply call our office.

Participating Insurance Companies
We currently are “in-network” with Regence, Metlife, Premera (Choice Network) and Delta Dental (Premier Network). We also bill “out-of-network” insurance plans. Although the majority of “out-of-network” plans pay the same as if you were “in-network,” some require that you pay a co-pay cost-share, some even reimburse you directly. As long as you provide us with updated and accurate information, we always do our best to let you know how your plan works before you come into our office. If you have any questions or concerns about your particular insurance plan, do not hesitate to contact the office. As a courtesy to our patients, we will be happy to file a claim on your behalf but ultimately the responsibility for payment of the claim belongs to the patients.

Please keep us informed of any insurance changes such as policy name, insurance company address, or a change of employment status.

*IMPORTANT NOTE ABOUT INSURANCE COVERAGE: Insurance providers we work with may change at any time and without notice. If you have any questions regarding your insurance provider, please contact our office.

Co-Payment and Cost-Share
Most plans pay 100% of services to our office. However, you may have noticed that sometimes your dental insurer reimburses you or our office at a lower rate than the actual fee incurred. Frequently, insurance companies state that the reimbursement was reduced because the fee has exceeded the usual, customary, or reasonable fee (“UCR”) used by the insurance company. The data used to establish fees may be dated and are set by the insurance company so they can make a profit. The goal of every insurance company is to collect more premiums than they pay out in benefits.

Insurance companies set their own schedules, and each company uses a different set of fees. These allowable fees may vary widely because each company collects fee information from claims it processes. The insurance company then uses this data to establish their fee schedule. Depending on the type of insurance you have and the exact nature of the plan, you may be responsible for the difference in what the insurance company pays and the fee assessed for services provided.  Unfortunately, insurance companies imply that your dentist is “overcharging” rather than say that they are “underpaying” or that their benefits are low. In general, the less expensive insurance policy will use a lower usual, customary, or reasonable (UCR) figure. Some plans pay on a “fee schedule.” If this is how your plan works, you may want to request the fee schedule and we can better estimate your coverage.

Payment is expected at the time services are provided by the person(s) accompanying the patient unless other arrangements have been made with our office in advance. In the event reimbursement is expected from a third party, it is the responsibility of the person(s) making the appointment and bringing the patient to the office to pay for services rendered and obtain reimbursement from third parties. Lakeview Kids’ Dentistry will not be responsible for obtaining payment from third parties. We will do our best to estimate your co-payment and cost-share before each appointment.

Additional Financial Information

  • No insurance pays 100% of all procedures
  • Benefits are not determined by our office

Keep in mind that dental insurance is meant to be an aid in covering dental care. On average, most dental insurance plans pay between 50%-80% of the average total fee. Some plans pay more, some pay less.

If we have received all of your insurance information on the day of the appointment, we will be happy to file your claim for you. You should be familiar with your insurance benefits, as we will collect from you the estimated amount insurance is not expected to pay. By law your insurance company is required to pay each claim within 30 days of receipt. We file claims in a manner such that your insurance company will receive claims within days of the treatment. You are responsible for any balance on your account after 30 days, whether insurance has paid or not. If you have not paid your balance within 60 days, a finance charge of $20 will be added to your account each month until paid. If you have not made payment arrangements with our office within 90 days of services being provided, your account may be frozen and referred for collection.  In the event payment cannot be made in full within the above referenced time frames, please call the office to discuss alternative payment plans. We will make every attempt to accommodate your situation.

Credit Cards

Our office accepts Visa, MasterCard and Discover cards.

Payment Plans

We expect all estimated patient portions and deductibles to be paid when service is provided. We implemented and enforce this policy to keep costs down for each of our patients. Therefore, we do not provide payment plans. Prior to treatment, our staff will provide an estimate of the treatment costs or co-pay. Usually the co-pay (cost-share) is a close estimate but in some cases an additional amount will be due.