Primary Insurance

Additional Insurance

Dental History

Medical History

Authorization

The above-named dentist may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the puepose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Protecting Your Confidential Health Information is Important to Us.

 Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW THE ALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GEE ACCESS TO THIS INFORMATION. PLEASE REVIEW PD CARERULLY

Our Promise 
Dear Patent

This notice is not meant to alarm you. Quite the oppesite! It is our desire to conumunicate to you that we are taking seriously Federal law (HUPAA Health Insurance Portability and Accountability Act) enacted to protect the contidentiality of  your health information We never want you to delay treatment because you are afraid  your personal health history might be unnecessarily made avaiable to others outside our office.

Why do vou have a privacy policy? Very good question! 

The Fedent! government legally enforces the importance of the privacy of health Information largely in response to the rapid evolution of computer technology and its use ut healthcare The government has appropriately sought to standardize and protect the privacy ef the clevironic exchange of your health infomation Chis has challenged us lo review not only how your health information is used within our computers but also with the Intemet, phone, faxes, copy machines, and charts. We believe this has been an important exercise for us because it has disciplined us to put in writing the policies and procedures we follow to protect your health information when we use it. 

We want you to know about these policies und procedures which we devclaped to make sure your health information will not be shared with anyone who does nut require tt Our office iy subyeet to State and Federal law regarding the confidentiality of your health information and in keeping with these laws, we want you to understand our procedures and your nyghts as our valuable patient.

We will use and communicate your HEALTH INFORMATION only for the purposes of providing your treatment, obtaining payment, conducting healthcare operations, and as otherwise described in this notice.

How Your HEALTH INFORMATION may be Used to Provide Treatment 

We wall use your HEALTH INFORMATION within our office to provide you with care. This may include adimnustrative and clinical offfice procedures designed to optimize scheduling and coordination of gare In addition, we tay share seur health iWfonnation will phannactes or other healthcare persunnel providing you treatment 

To Obtain Payment 

We may include your health information with an invoice used to collect payment for treatment you receive in our office. We may do this with insurance forms field 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.

To Conduct Health Care Operations 

Your health information may be used during performance evaluations of our staff. Some of our best teaching opportunities use clinical situatians experienced by patients receiving care at our office. As a result, health information may be included in training programs for students, interns, associates, and business and clincal employees. It is also possible that health information will be disclosed during audits by insurance companies or goverment appointed agencies as part of their quality assurance and compliance reviews. Your health information may be reviewed during the routine processes of ectification, licensing or credentialing activities.

In Patient Reminders 

Because we believe regular care is very important to your health, we will remind you of a scheduled appointnent of that it is time for you to contact us and make an appointment. Additionally, we may contact you to follow up on your care and inform you of treatment options of services that may be of interest to you or your family, These communications are an important part of our philosophy of partnering with our patients to be sure they receive the best care. They may include pastcards, folding postcards, letters, telephone reminders or electronic reminders such as email (unless you tell us that you do not want to receive these reminders)

To Business Associates 

We have contracted with one or more third parties (referred to as a business associate) to use and disclose your health information to perform services for us, such as billing services. We will obtain cach business associate's written agreement to safeguard your health information. 

NOTICE OF PRIVACY PRACTICES 

Federal law generally permits us to make certain uses or disclosures of health information without your permission. Federal law also requires us to list in the Notice each of these categories of uses or disclosures. The listing is below. 

As Required By Law 
We may use or disclose your health information as required by any statute, regulation, court order or other mandate enforceable in a court of law. 

Abuse or Neglect 
We may disclose your health information to the responsible government agency if (a) the Privacy Official reasonably believes that you are a victim of abuse, neglect, or domestic violence, and (b) we are required or permitted by law to make the disclosure. We will promptly inform you that such a disclosure has been made unless the Privacy official determines that informing you would not be in your best interest. 

Public Health and National Security 

We may be required to disclose to Federal officials or military authoritics 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 of 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. 

To The U.S. Department of Health and Human Services (HHS) 
We may disclose your health information to HHS, the government agency responsible for overseeing compliance with federal privacy law and regulations regulating the privacy and security of health information.

For Research 
We may use or disclose your health information for research, subject to conditions “Research” means systemic investigation designed to contribute lo generalized knowledge. 

In Connection With Your Death or Organ Donation 
We may disclose your health information to a coroner for dentitication purposes, to a funeral director for funeral purposes. or to an organ procurement organization to facilitate transplantation of one of your organs.

If applicable State law does not permit the disclosure described above, we will comply with the stricter State law. 

Authorization to Use or Disclose 
Health Information 
We are required to obtain your written authorization in the following circumstances: (a) to use or disclose psychotherapy notes (except when needed tor payment purposes or to defend against litigation filed by you), (b) to use your PHT for marketing purposes: (c) to sell your PHT, and (d) to use ot disclose your PHI for any purpose not previously described in this Notice. We also will obtain your authorization before using or disclosing your PHI when required to do so by (a) state law, such as laws restricting the use or disclosure of genetic information of information concerning HIV status, or (b) other federal law, such as federal taw protecting the confidentiality of substance abuse records. You may revoke that authorization in writing at any time.

PATIENT RIGHTS 

You have the following rights related to your health information.

Restrictions 

You have the right to request restrictions on the use of disclosure of your health information for treatment, payment. or healthcare operations in addition to the ristrictions imposed by federal law. Our office is not required to agree lo your request. unless (a) you request that we not disclose your PHI to a health insurance company, Medicare or Medicaid for payment or healthcare operations purposes: (b) you, or someone on your behalf, has paid us in full for the healthcare item or service to which the PHI pertains, and (c) we are not required by law to disclose to the insurer, Medicare, or Medicaid the PHI that is the subject of your request, but we will endeavor to honor reasonable requests. We generally are not required to agree to a requested restriction. Our office will honor your request that we not disclose your health information to a health plan for payment or healthcare operation purposes if the health information relates solely to a healtheare item or service for which vou have paid us out-of-pocket in full.

Confidential Communications 

You have the right to request that we communicate with you by alternative means or at an altenative location You may, for example, request thal we Communicate your health information only privately with no other family members present of through mailed communications that are scaled We will honer your reasonable requests for confidential Communications.

Inspect and Copy Your Health Information 

You have the right to read, review, and copy your health informatian, including your complete chart, x-rays and billing records If you would lke a copy ot your health information. please let us know. We may need to charge you a reasonable, cost-based fee to duplicate and assemble your copy. If there will be a charge, we will first contact you to determine whether you wish to modity or withdraw your request. 

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 lang as our office maintains this information. In order to standardize our process. please provide us with your request in writing and describe the information to be changed and your reason for the change. 

Your request may be denied if the health information record in question way not created by our office, is not part of our records or if the records containing your health information are determined to be accurate and complete If we deny your request, we will provide you with a wotten explanation of the denial.

Accounting of Disclosures of Your 

Health Information 

You have the right to ask us for a description of how and where your health information was disclosed. Our documentation procedures will enable us to provide information on health information disclosures that we are required to disclose to you. Please let us Know in writing the time period for which you are interested. Thank you for limiting your request to no more than six years at a time. We will provide the first accounting during any 12-month period without charge. We may charge a reasonable, cost-based fee for each additional accounting dunng the same |2-month penod If there will be a charge, the Privacy Official will first contact you to determine whether you wish to modify or withdraw 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 Stop by or give us a call and we will mail or email a copy to you. 

Receive Notice of a Security Breach 

You have the right to receive notification of a breach of your unsecured health information. 

Changes to the Notice 

We are required by law fo maintain the privacy of vour health information and to provide to you of your personal representative with 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 .

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. We will not retaliate against you for submitting a complaint, Please let us know of your concems or complaints in writing by submitting your complaint to our Privacy Officer. 

Thank you very much for taking time to review how we are carefully using your health information. If you have any questions we want to hear from you. If not, we would appreciate very much your acknowledging your receipt of our poliicy by signing this form.

For additional information about the matters discussed in this notice, please contact our Privacy Officer.

Office Policies 

Financial Agreement 

All patients are ultimately responsible for all fees generated by their treatment. We are happy to submit all claims to your Insurance company to help you receive the full benefit of your coverage, but all patients are directly responsible for all charges. If your Insurance company does not return full payment within 30 days of our submission of your claims, we will inform you of any discrepancy so that you may speak directly with your insurance provider. Should a shortfall in payment still exist 60 days after submission of your claim, you will be billed directly for any remainder. 

Because insurance policies vary, we can only estimate your coverage In good faith but cannot guarantee coverage due to the complexities of insurance contracts. 

Appointments

Please arrive on-time to your scheduled appomtment. Late arrivals cause schedule delays for those patients who arrive promptly at their appointment time. Late arrivals will be worked into the schedule if time allows or re-appointed to another day. 

Cancellations/Missed Appointments 

In an effort to decrease unnecessary costs related to staffing and supplies and in order to contain our costs and continue to provide you with affordable fine dentistry for your entire family, we maintain a Cancellation Policy for all of our patients. To promote efficient access to our clinic, we require that any appointment that is no longer needed or is unable to be kept, must be cancelled at least 24 hours in advance of the appointment. Cancellations must be made during normal business hours on workdays at least one full business day before the scheduled appointment. Cancellations must be done over the phone by speaking directly to one of our dental professionals. Patients will not be charged if cancellation is made 24 business hours before their appoinhment. We reserve the right to charge any patient who misses an appointment without adhering to our cancellation policy a missed appointment fee of $ 50.

I have read and understand the Office Policies of the practice and I agree to be bound by its terms. I also understand and agree that such terms may be amended from time-to-time by the practice.