Skippy Consent

Child's Personal Information

Child's Health History

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PAYMENT INFORMATION - YOU MUST COMPLETE AND SIGN AT BOTTOM

If you have Dental Insurance, Medicaid or CHP+ we will bill for services. If your child currenty receives dental care with a dentist, participation in Skippy is a duplication of those services and can result in denied insurance coverage for dental care.

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If yes, please complete the information below:

Employer Information


Consent: The information on this page and the health history are correct to the best of my knowledge. I agree and authorize Tri-County Health Network's (TCHNetwork) licensed dentist and dental hygienists to perform the above stated dental services as needed. I further understand that for the sustainability of the program, my insurance will be billed, if applicable. I request and authorize the release of any information on this form and acquired in the course of treatment for payment and referral purpose as deemed necessary by TCHNetwork. I also authorize TCHNetwork to submit claims to my insurance company on my behalf, and my insurance company to pay benefits directly to TCHNetwork, as applicable. Should any insurance payment be made directly to the insured for monies due on this account, I agree to immediately pay over these funds to TCHNetwork.

Electronic Signature Agreement: The parties agree that this agreement may be electronically signed. The parties acknowledge that electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability and admissibility.

(Use your mouse or trackpad to sign.)

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