Welcome To Our Practice

Please take a few minutes to answer the following questions so we can better assist you with your health care needs.






I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Kumra Orthodontics all insurance benefits if any, otherwise payable to me for services rendered. 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 payments of benefits. I authorize the use of this signature on all insurance submissions.






Generally, excellent orthodontic results can be achieved with informed and cooperative patients. You should be aware that orthodontic treatment, like treatment of any part of the body, has some risks and limitations. These are seldom severe enough to offset the advantages of treatment, but should be considered in making the decision to undergo orthodontics.

Decay, gum disease and permanent markings on teeth can occur if patients do not brush frequently and properly or eat hard or sticky foods, or foods with excessive sugar.

A tooth that has been traumatized by a blow or large filling may require Endodontics (root canal) when it is moved with orthodontic appliances. Sometimes a tooth may have a non-vital pulp (nerve) and orthodontic movement may make the need for endodontic treatment apparent.

In some cases, the length of the roots of some teeth may be shortened during orthodontic treatment. Usually this is of no consequence, but on rare occasions it is a serious threat to the longevity of the teeth involved.

Teeth have a tendency to return toward their original position after treatment. Usually this is only minor. Faithful wearing of retainers reduce this tendency. A common site for these changes is the lower front teeth and some changes in this area should be expected.

Occasionally a person who has had normal growth of the jaws may not continue to do so. If growth becomes disproportionate, the relationship of the upper jaw to the lower jaw may change, requiring additional treatment, or, in some cases, surgery. Growth disharmony is a biological process beyond the orthodontist’s control.

There is a risk that problems may occur in the temporomandibular joints (TMJ) just in front of the ear. Orthodontic treatment can improve dental cause of TMJ pain, but not in all cases. In moving the teeth to new position, the jaws may be uncomfortable for a while.

The total time for treatment can be longer than our estimated time. Lack of bone growth, poor cooperation, broken appliances and missed appointments are important factors which can lengthen treatment and affect the quality of the result.

I have read, understand and of the above consent to treatment.*



  • The total case fee for your orthodontic treatment is submitted to your insurance company when treatment begins. The “banding date” is the date on which treatment officially begins; this is the day bands or brackets are placed on the teeth. Placing separators does not constitute treatment starting.
  • Insurance payments are paid to the orthodontic office either monthly, quarterly, or annually. It is a rare exception that a one- time payment for the entire lifetimemaximum is made initially.
  • During Orthodontic treatment, if insurance coverage is interrupted for any reason, insurance payments stop. Reason may include a job change, your employer changing insurance carriers, your coverage is dropped, or treatment ends. If an insurance change occurs during treatment, it is the patient’s responsibility to inform the office so we can file a new claim. A new insurance company will not know you are in orthodontic treatment.
  • When our office confirms orthodontic benefits,the insurance company is very clear that the benefit information we are given is an estimate and no guarantee of payment. In our orthodontic financial agreement, the insurance allowance we take assignment for is an “estimate.” We never know for sure how long or even if we will be paid until it actually happens. If for any reason the total insurance assignment is not paid as expected, it becomes the responsibility of our patient or responsible party. If the insurance company retains a portion of the benefit to cover your deductible, you will be responsible for reimbursing that deductible to our office.
  • Our office is happy to file and insurance claim on our patient’s behalf; however once the initial carrier has paid the insurance balance in full, we will be able unable to file an additional claim should you become insured with another carrier. We will be happy to provide you with the information you need to file the claim yourself.
  • Some insurance companies (ex. Delta Dental) use orthodontic benefits to pay for procedures done at other providers’ offices, esp oral surgery. If a procedure from another provider’s office is paid for with orthodontic benefits, you will be responsible for the difference not paid to our office by your insurance company.
  • Some insurance companies place a contingency of medical necessity on orthodontic claim payments. If your insurance company determines that your treatment is not medically necessary, you will be responsible for the estimated insurance portion.
  • Our office may not be aware of your policy’s status under the Affordable Care Act. Under these provisions, benefits are only provided for children with serious orthodontic impairment resulting from congenital abnormalities that affect their daily ability to function, like eating and speaking. Your insurance company will review your child’s case before approving or denying coverage for the treatment.
  • This is a general explanation.Please keep in mind that your policy may be different.I have been informed of the treatment plan and associated fees. I agree to be responsible for all charges for dental services and materials not paid by dental plan, unless prohibited by law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To extent permitted by law, I consent to your use and disclosure of my protected health information to carry out payment activities in connection with my claim.

I have read, understand and of the above consent to treatment.*


HIPAA – Notice of Privacy Practice

HIPAA is a federal law developed to provide a standard for the protection of your health information. The purpose of the Notice of Privacy Practice is to explain how Kumra Orthodontics may use or disclose your health care information. The Notice also explains the rights that you are guaranteed under HIPAA regulations. Though Kumra Orthodontics has always taken great care to protect the integrity and confidentiality of your health care information, we are now required by the HIPAA Privacy Rule to distribute this notice to you and obtain acknowledgment that you have received the Notice. Signing below indicates that you have received the Notice of Privacy Practice.

I hereby acknowledge that I have received a copy of Kumra Orthodontics Notice of Privacy Practices.*


Permission to Share Medical/Dental Information

My Medical/Dental information may be obtained and exchanged verbally to my Medical/Dental Provider.

I have read, understand and of the above consent to treatment.*

E-mailing X-rays

In providing the best treatment for our patients, it might be necessary for us to e-mail x-rays to other specialists or dentists. This allows other offices to have a better diagnostic tool available to them which will cost you less and permit you to have access to quicker service.

I understand that x-rays might need to be e-mailed to other specialists and dentists. I give my permission for this service.*

Photo and Video Release

I hereby grant permission to Dr. Bob Kumra to use my or my child's photograph or video and any testimonial given regarding the dental care received from his office towards the marketing/advertising of his practice and for teaching purposes. This includes use on Dr. Kumra's website, Facebook, Instagram, marketing materials, and any other social media platforms. I acknowledge Dr. Kumra‘s right to prepare the photographs at his discretion (ie Add a logo, adjust the contrast/brightness, etc...). I also acknowledge that Dr. Kumra may choose not to use my photographs or videos and testimonial at this time, but may do so at his own discretion at a later date. I agree that I will not hold Dr. Kumra responsible for the use of these photographs and videos.

I hereby freely voluntarily consent to the use of my child’s photograph/video as stated above until I revoke this consent in writing.*

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform the office of any changes in my medical status. *