Although we primarily treat the area in and around your mouth, we know that your mouth is a part of your entire body. Existing health problems that you may have, or current medications that you may be taking, could have an important interrelationship with the treatments you will receive. We thank you for answering the following questions accurately.
I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by Dr. Yolanda Cintron to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist. I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all the charges whether or not paid by insurance. I understand that I will be responsible for any collection costs and attorney fees if I fail to honor my financial obligation for my dental treatment. I authorize Dr. Yolanda Cintron to use any image or video recording of me to diagnose, develop a treatment plan, for patient viewing / education and any form of marketing. To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in address, insurance info and medical status. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my surgeon, or any other member of his/her staff, responsible for any errors or omissions that I have made in the completion of this form.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Please Review It Carefully
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and controls your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present, and future physical, dental or mental health condition and related health care services.
If we have HIV or substance abuse information about you, we cannot release that information without a special signed, written authorization from you. This is different than the authorization and consent mentioned above. In order to disclose these types of records for purposes of treatment, payment or health care operations, we will have to have both your signed Consent and a special written authorization that complies with the law governing HIV or substance abuse records.
You have the right to inspect and copy your health information, such as medical and billing records, that we use to make decisions about your care. In order to do so, you must submit a written request to inspect and/or copy your health information. Your request may be denied in certain limited circumstances. However, if you are denied, you may ask that the denial be reviewed. We will comply with the outcome of the review. You have the right to request a correction or change to your health information if you believe it is incorrect or incomplete. Your request must be in writing and include a reason to support the request. We may deny your request if you ask us to amend information that:
a) We did not create unless the person or entity that created the information is no longer available to make the amendment.
b) Is not part of the health information that we keep.
c) You would not be permitted to inspect and copy.d) Is accurate and complete.
You have the right to request an accounting of disclosures.
This is a list of the disclosures we made of medical information about you for purposes other than treatment, payment, and health care operations. To obtain this list, you must submit your request in writing which states a time period no longer than six years and does not include dates before April 14, 2003. We may charge you for the costs of providing the list, either electronically or paper copy. However, you may choose to withdraw or modify your request at that time before any costs are incurred.
You have the right to be assured that your information will be kept confidential. You may request that we communicate with you about medical matters in a certain way or at a certain location. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
You have the right to a paper copy of this notice. If you have agreed to receive it electronically, you are still entitled to a paper copy. You may ask us to give you a copy of this notice at any time by contacting the Privacy Officer, Office of theGeneral Counsel.
Changes to This Notice We reserve the right to change this notice, and to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a summary of the current notice in the office with its effective date. You are entitled toa copy of the notice currently in effect.
Complaints you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the U.S.Department of Health and Human Services. You will not be penalized for filing a complaint.
For Further Information, Requests for further information about the information covered in this notice may be directed towards the person who gave you the notice or our Privacy Officer, The International Center For Dental Excellence, 2021 E. Commercial Blvd. #208, Ft. Lauderdale, FL 33334 or by phone at (954) 938-4599. The International Center For Dental Excellence – Dr. Yolanda Cintron D.M.D., P.A. - August 12, 2014.
I hereby acknowledge that I have received and read this Notice of Privacy Practices.
Medical Records Release Form
Access and Authorization for Use and/or Disclosure of Protected Health Information
I authorize Dr. Yolanda Cintron DMD, PA to release confidential health information including but not limited to X-rays, photos, clinical findings, treatment notes , lab reports, medical histories, medications and other by email, phone, fax, and mail. I am giving permission to discuss post op instructions with your chosen responsible party that will be picking you up when you are sedated.