APPOINTMENT POLICIES – PLEASE READ

All estimated co-payments and balances must be paid the same day services are rendered, unless other financial arrangements were made previously.

Patients with insurances are responsible for any amount not paid by insurance. As a courtesy, we provide an estimate on what your insurance will pay. However, too many factors with the Insurance companies can lead to these estimates being incorrect. Please don’t hesitate to ask any questions to our staff.

No crowns, bridges, dentures, or any other treatment requiring lab work will be sent out without a deposit of at least 50% and must be paid in full before being seated for insertion.

There is a broken appointmentfee that will be strictly enforced for any patient who fails to cancel or reschedule their appointment 48 hours in advance (outside of a true emergency).  The charge is $50 per 1 hour appointment time, which will be donated on behalf of your name to Kinder Smile Foundation, which YOU will receive a tax credit for. (Kinder Smile Foundation provides free dental care to children who cannot afford it).  You cannot text or leave voicemails to cancel/reschedule your appointment outside of office hours.

 

PLEASE NOTE: WHEN CANCELLING OR RESCHEDULING AN

APPOINTMENT IT MUST BE DONE DURING OUR OFFICE HOURS

To help our efforts to see patients as close to their appointment time, any patients arriving 10 minutes or more after their scheduled time may need to be rescheduled.

Please help us provide timely and excellent care by confirming your appointment – we made it easy! – all you have to do is reply YES to the text reminder! We reserve the right to schedule another patient if you do not confirm your appointment 48 hours from your appointment time, and the broken appointment fee will be enforced.

Notice of Financial Policies and Federal Truth-in-Lending Statement

As a condition of your treatment by this office, financial arrangements must be made in advance. The practicedepends upon reimbursement from our patients for the costs incurred in their care to remain viable.Therefore, financial responsibility on the part of each patient must be determined before treatment. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for at the time services are rendered.

Patients who carry dental insurance understand that all dental services provided are charged directly to the patient and that he or she is personally responsible for payment of all dental services. As a courtesy, this office will help prepare the insurance forms of our patients or assist in making collections from insurance companies and will credit any such collections received to the patient’s account. Patient copays and insurance coverage amounts are provided as an estimate - with so many variations of plans and employers, we cannot guarantee the amounts estimated.  Furthermore, this dental office cannot render services on the assumption that our charges will be paid in full by an insurance company. If we do not receive payment from your insurance company within 60 days, you will be responsible for payment of your treatment fees and collection of your benefits directly from your insurance carrier.

A service charge of 1.5% per month (18% APR) on the unpaid balance may be assessed on all accounts exceeding thirty (30) days from the date of service unless previously written financial arrangements are made. There is a $5 late payment fee. I understand that the fees on the treatment plan are valid only for a period of six (6) months from the date of the patient examination.

In consideration for the professional services to be rendered to me (or at my request, to my minor child orward) by the Dentists or authorized agent of Jersey City Dental, I agree to pay the fees charged for the dental services provided by the Dentists or licensed employee at the time the services are rendered, or within ten (10) days of billing if credit is extended by the office. In the event my account becomes delinquent, I agree to pay the remaining balance plus the sum of the collection commission charged by the collection agency to which a delinquent account is turned for collection, in addition to reasonable attorney fees and court costs where such legal services are necessary. I authorize the release of financially identifiable information concerning my account, including charges billed, payments made, and interest charges assessed, etc. to the practice’s collection agency or attorney should collection procedures as described become necessary.

I grant my permission to you or your assignee to telephone, text or email me at home or at my workplace to discuss matters related to this form.

This agreement supersedes all prior agreements signed, including any and all mediation or mediation/arbitration agreements. I acknowledge that any prior mediation or mediation/arbitrationagreements signed previously related to financial arrangements or quality of care are null and void. I authorize the practice or its designees to release financially identifiable information and treatment descriptions and information, either electronically, by facsimile or in paper form to my insurance carrier or any related entities that require such information to be submitted. I also authorize payment directly to Jersey City Dental insurance benefits otherwise payable to me.

I have read and hereby agree to abide by the conditions outlined herein.

Patient, legal guardian or authorized agent of patient)

Jersey City Dental

75 Montgomery St. STE 402 Jersey City, NJ 07302

Choosing among dentally reasonable treatment alternatives is a shared responsibility of dentists and patients. In the usual case, a dentist will recommend a course of treatment. While a patient often decides to adopt the recommendation, the ultimate decision is for the patient provided the choice is dentally reasonable. Under the law in New Jersey, a dentist is obligated to inform a patient of dentally acceptable treatment alternatives and their attendant probable risks and outcomes, and the costs relative to the treatment that is recommended and/or rendered, so a patient can make a decision that is informed. This form, together with our conversation about treatment alternatives, risks and outcomes, is intended to fulfill Dentist’s legal obligation to obtain informed consent.

1.Treatment Plan as presented.

2.Changes in Treatment Plan. During the course of treatment, procedures may need to be added, expanded or changed because conditions are found that were not identified during examination and first were observed during the course of treatment. The most common include the need for root canal therapy and more extensive restorative procedures, like crowns, bridges or implants. Permission is hereby given to perform any additional or expanded dental services that the Dentist determines are necessary, teh cost of which is my responsibility. Further, in the Dentist’s discretion, I may be referred to a specialist for further treatment, the cost of which is my responsibility.

3.Drugs, Medications and Sedation. Drugs, medications or anesthesia/sedation can cause allergic and other reactions. Examples include, but are not limited to, swelling, redness, itching, vomiting, diarrhea, numbness or tingling of the lip, gum or tongue (which in rare cases may be permanent) and also in rare cases, anaphylactic shock. Since they also may cause drowsiness and impair coordination or awareness, a motor vehicle or hazardous device should not be operated before full recovery is achieved. I have informed the dentist of all drugs and medications I am taking or have taken within the last 30 days as well as those that have been prescribed within the last 6 months but not taken, and all allergies and sensitivities of which I am aware. I have been informed and understand that failure to take drugs or medications as prescribed by Dentist may result in continued or aggravated infection and pain and potential resistance to effective treatment. In addition, antibiotics can reduce the effectiveness of birth control pills.

4. Fillings. The most common conditions encountered with fillings are pain, sensitivity to temperature or pressure, fractures of teeth or roots, nerve damage, damage to other teeth, occlusal (bite) discrepancies, temporomandibular joint problems and occasional allergic reactions to filling materials.  Some instances, a filling may result in a tooth needing a root canal, the cost of which is my responsibility.

5.Endodontic Treatment (Root Canal Although root canal treatment to retain a tooth or teeth that otherwise might need to be extracted is a very common dental procedure with a reported success rate over 80%, there are some risks and complications. The most common include swelling, soreness, infection, bleeding, trismus (restricted jaw opening), numbness or tingling of the lip, gum or tongue (which in rare cases may be permanent), discoloration of adjacent teeth or soft tissue, perforation of the root, and fractures (splits) of the crown or root of the tooth or restoration. Occasionally, one of the delicate instruments used to perform a root canal may break in the tooth. A failed root canal may require re-treatment, surgery or extraction. Once a tooth has received root canal treatment, it tends to be more brittle and weak. To minimize the likelihood of a fracture, restoration with a crown is recommended. There is no guarantee that root canal treatment will save a tooth.

6. Crowns, Onlays/Inlays, Bridges, Veneers and Bonding. Sometimes, it is difficult or impossible to exactly match the color of artificial teeth or restorative materials with natural teeth. Although assistance will be provided by the Dentist, it is my responsibility to make changes, if any, (including, for example, shape, size, fit and color) before permanent cementation. After a temporary crown has been placed, it is essential to have the new crown cemented as soon as it is ready because the temporary crown is not intended to function as a permanent restoration. Failing to replace the temporary crown could lead to decay, gum disease, infections, problems with the bite and even loss of the tooth. Further, if there is a prolonged delay in placing the permanent crown, it may no longer properly fit. In some instances, the tooth prepared for a crown, onlay, inlay, bridge, or veneer may lead to more treatment, most commonly a root canal, the cost of which is my responsibility.

I acknowledge it is my responsibility to discuss treatment alternatives, risks, outcomes and costs with the Dentist and will have any questions answered before making a decision to undergo treatment.  I understand that dentistry is not an exact science and that there are no guaranteed results. Unless otherwise provided by law, I understand that I am responsible for payment of all dental fees not paid in full by any insurance or other applicable coverage. Having had adequate time to reflect upon the alternatives, I consent to the treatment, subject to changes in treatment plan, that has been or will be presented to me in detail by the Dentist.

If Guardian signing, please provide name of Guardian

I give consent to Jersey City Dental to take photographs of me for use in dental and/or medical teaching and writing, as well as for demonstrating before and after photos either on the web or in a booklet for the waiting room. The patient’s name or any other personal information will never be used.

These photographs will be used to aid in cosmetic dentistry with coordination with the lab.  They may be published in dental and/or medical books, journals. Also, they may be displayed on dental and/or medical Internet sites. My images may be used in order to advance dental and/or medical knowledge, practice, or education.

If full face pictures are taken, I understand it is my responsibility to notify Jersey City Dental if I do not want this particular photo to be used.

 

Your health care is important to us. In order to provide you with the best possible care, we occasionally send convenient text messages and/or emails to our patients about their health care and the products and services we offer.

You are currently set to receive text messages and/or emails for appointment reminders and information about your health care treatment, as well as promotions or other services we offer.  If you do not wish to receive these communications, please let the office know.  Please keep in mind by removing yourself from this feature, you will no longer get convenient appointment reminders, updates, and promotions as well as lose the ability to text or email us for appointment changes or any general questions.

We look forward to providing better and more convenient communications with you via text and email messaging. Our goal is to provide you with relevant and useful information about your health care and the products and services we offer for improving your health. We will not disclose your mobile number or email to any third party.  It will strictly be used to inform you of your oral health related information and periodic promotions or special messages.

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

THIS PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect on the date of signature below, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provide such changes are permitted by applicable law. We reserve the right to make changes in our privacy practices and in the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, please let the office know. Or, for additional copies of this Notice, please contact us using the information at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider pending treatment to you.

Payment: We may use or disclose your health information to obtain payment for services we provided to you.

Healthcare operations: We may use or disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, and certification licensing or credentialing activities.

Our Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. You revocation will not affect any use of disclosures permitted by your authorization while it was in affect. Unless you give us written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make responsible inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required By Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose the authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institutions or law enforcement officials having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail, text, and email messages, postcards or letters).

PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format your request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee.

Contact us using the information at the end of this Notice for a full explanation of our fee structure.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, health operations and certain other activities, for the last six years, but not before April 14, 2003. If you request this accounting more than once in 12-month period, we may charge you a reasonable, cost based fee for responding to these additional requests.

Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means, to alternative locations. (You must make your request in writing). Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended). We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our Web site or by Electronic mail (e-mail), you are entitled to receive this notice in written form.

QUESTIONS AND COMPLAINTS

If you want more information on our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us by using the contact information at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint to the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with the U.S. Department of Health and Human Services For more information about HIPAA or to file a complaint:

The U.S. Department of Health and Human Services Office of Civil Rights 200 Independence Avenue, S.W. Washington, DC 20201 202/619-0257 Toll free: 1/877-696-6775

ACKNOWLEDGEMENT OF RECEIVING NOTICE OF PRIVACY PRACTICES