HIPAA CONSENT FORM

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

• Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment).
• Obtaining payment from third party payers (e.g. my insurance company).
• The day-to-day health care operations of your practice.

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.

NEW PATIENT MEDICAL HISTORY

Do you have or have you had?

DENTAL INFORMATION

Do you?

Have you

Women Only

RICHARDSON - OVERSTREET - GLAZIER, LTD.

4909 GROVE AVENUE RICHMOND, VIRGINIA, 23226 PHONE: 804-355-6593 FAX: 804-358-6394

EXCELLENCE IN PERIODONTICS

11301-B POLO PLACE MIDLOTHIAN, VIRGINIA, 23113 PHONE: 804-794-7094 FAX: 804-794-9858

PATIENT INFORMATION (CONFIDENTIAL)

Responsible party (If different from above)

Insurance Information

We are out of network provider for all insurance carriers 

Pharmacy Information

FINANCIAL POLICY

WE ARE OUT-OF-NETWORK PROVIDERS FOR ALL INSURANCE CARRIERS

HOWEVER. IF YOU WOULD LIKE FOR US 10 ASSIST YOU IN PROCESSING YOUR INSURANCE FORMS. WE NEED TO HAVE. YOUR SIGNATURE ON FILE. THIS GIVES US HIE AUTHORIZATION TO RELEASE TREATMENT INFORMATION TO YOUR INSURANCE CARRIER AND AUTHORIZES THEM TO PAY BENEFITS DIRECTLY TO (IS TO BE APPLIED AGAINST YOUR ACCOUNT. IF, AFTER 90 DAYS YOUR INSURANCE HAS NOT PAID, A STATEMENT WILL BE ISSUED TO THE RESPONSIBLE PARTY.

BY HAVING YOUR SIGNATURE ON FILE, WE CAN USE OUR OWN COMPUTER-GENERATED FORMS. WHICH MAY NOT BE AVAILABLE FOR YOU TO SIGN WHEN YOUR TREATMENT IS PROVIDED.

YOUR SIGNATURE ON THIS FORM ALSO CONFIRMS THAT YOU HAVE BEEN OFFERED THE OPPORTUNITY TO READ THE PATIENT'S RIGHTS FORM, WHICH IS POSTED IN THE RECEPTION AREA. 

AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize Richardson-Overstreet, Ltd. to release any information relating to my dental treatment.

ANY PATIENT WHO FAILS TO SHOW UP FOR AN APPOINTMENT WITHOUT GIVING 24 HOURS NOTICE MAY BE SUBJECT TO A BROKEN APPOINTMENT CHARGE OF $75.00.

FOR VALUE RECEIVED THE UNDERSIGNED HEREBY GUARANTEES PAYMENT TO RICHARDSON-OVERSTREEE LTD. OF ALL CHARGES INCURRED IN THE PAST AND TO BE INCURRED IN THE FUTURE BY THE UNDERSIGNED AND THE PATIENT NAMED ON THE REGISTRATION FORM, AND IF MY ACCOUNT HAS TO BE TURNED OVER TO AN ATTORNEY FOR COLLECTION, I AGREE TO PAY ALL COSTS OF COLLECTION. INCLUDING ATTORNEY'S FEES EQUAL TO 33.3% OF ALL SUMS DUE AND OWING. A TWENTY-FIVE DOLLAR ($25) FEE WILL BE CHARGED FOR ALL RETURNED CHECKES I ALSO HEREBY ASSIGN UNTO RICHARDSONOVERSTREET, LTD. ANY AND ALL INSURANCE BENEFITS TO WHICH I AM ENTITLED UNDER ANY POLICY OF INSURANCE (HEALTH, DENTAL, AUTOMOBILE OR ANY OTHER).

PATIENT RIGHTS

THIS NEW LAW IS CAREFUL TO DESCRIBE THAT YOU HAVE THE FOLLOWING RIGHTS RELATED TO YOUR HEALTH INFORMATION

Restrictions: You have the right to request restrictions on certain uses and disclosures of your health information. Our office will make every effort to honor reasonable restriction preferences from our patients.

Confidential Communications: You have the right to request that we communicate with you in a certain way. You may request that we only communicate your health information privately with no other family members present or through mailed communications that are sealed. We will make every effort to honor your reasonable requests for confidential communications.

Inspect and Copy Your Health Information: You have the right to read, review and copy your health information, including your complete chart, x-rays and billing records. If you would like a copy of your health information, please let us know. We may need to charge you a reasonable fee to duplicate and assemble your copy.

Amend Your Health Information: You have the right to ask us to update or modify your records if you believe your health information records are incorrect or incomplete. We will be happy to accommodate you as long as our office maintains this information. Your request must be in writing and must explain why the information should be amended. Your request may be denied if our office did not create the health information record in question, is not part of our records or if the records containing your health information are determined to be accurate and complete.

Documentation of Health Information: You have the right to ask us for a description of how and where your health information was used by our office for any reason other than treatment, payment or health operations for the last 6 years but not before April 14, 2003. Please let us know in writing the time period for which you are interested. We may need to charge you a reasonable fee for your request.

Request a Paper Copy of this Notice: You have the right to obtain a copy of this Notice of Privacy Practices directly from our office at any time. We are required by law to maintain the privacy of your health information and to provide to you and your representative this Notice of Our Privacy Practices. We are required to practice the policies and procedures described in this notice but we do reserve the right to change the terms of our Notice. If we change our privacy practices, we will be sure all of our patients receive a copy of the revised Notice.

Questions and Complaints: You have the right to express complaints to us or to the Secretary of Health and Human Services if you believe your privacy rights have been compromised. We encourage you to express any concerns you may have regarding the privacy of your information. Please let us know in writing of your concerns or complaints.

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND 110W YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE READ THIS CAREFULLY. TIIE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

HOW YOUR HEALTH INFORMATION MAY BE USED.

Treatment: We will use your health information within our office to provide you with the best dental care possible. This may include administrative and clinical office procedures designed to optimize scheduling and coordination of care between hygienists, dental assistants, dentists and business office staff. In addition, we may share your health information with physicians, referring dentists, dental laboratories, pharmacies or other health care personnel providing your treatment.

Payment: We may use and disclose your health information to obtain payment for services we provide to you. We may do this with insurance forms filed for you in the mail or sent electronically. We will be sure to only work with companies with a similar commitment to the security of your health information.

Healthcare Operations: We may use and 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, certification, licensing or credentialing activities.

Appointment Reminders: Because we believe regular care is very important to your oral and general health. we will remind you of a scheduled appointment or that it is time for you to contact us to make an appointment. These reminders may include postcards, letters, telephone reminders or electronic reminders, such as e-mail (unless you tell us that you do not want to receive these reminders).

Abuse or Neglect: We will notify government authorities if we believe a patient is the victim of abuse, neglect or domestic violence. We will make this disclosure only when we are compelled by our ethical judgment, when we believe we are specifically required or authorized by law or with the patient's agreement. Family,

Friends and Caregivers: We may share your health information with those you tell use will be helping you with your home hygiene, treatment, medications or payment. We will be sure to ask your permission first. In the case of an emergency, where you are unable to tell us what you want, we will use our very best judgment when sharing your health information only when it will be important to those participating in providing your care.

Public Health and National Security: We may be required to disclose to Federal Officials or military authorities health information necessary to complete an investigation related to public health or national security. Health information could be important when the government believes that the public safety could benefit when the information could lead to the control or prevention of an epidemic or the understanding of new side effects of a drug treatment or medical device.

For Law Enforcement: As permitted or required by State or Federal Law, we may disclose your health information to a law enforcement official for certain law enforcement purposes, including, under certain limited circumstances, if you are a victim of a crime or in order to report a crime.

Your 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. You may revoke your authorization in writing at any time. Unless you give us written authorization, we cannot use or disclose your health information for any reason except those described in this notice.