Notice of Privacy Practices

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.

If you have any questions about this Notice please contact our Privacy Officer or any staff member in our office.

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out your treatment, collect payment for your care and manage the operations of this clinic. It also describes our policies concerning the use and disclosure of this information for other purposes that are permitted or required by law. It describes your rights to access and controls your protected health information. "Protected Health Information" (PHI) is information about you, including demographic information that may identify you, that relates to your past, present, or future physical or mental health or condition, and related health care services.

We are required by Federal law to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. The new notice will be effective for all protected health information that we maintain at that time. You may obtain revisions to our Notice of Privacy Practices by accessing our website, calling the office, and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

By applying to be treated in our office, you are implying consent to the use and disclosure of your protected health information by your doctor, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to bill for your health care and to support the operation of the practice.

Following are examples of the types of uses and disclosures of your protected health care information we will make, based on this implied consent. These examples are not meant to be exhaustive but to describe the types of uses and disclosures that may be made by our office.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to your protected health information. For example, we would disclose your protected health information, as necessary, to another physician who may be treating you. Your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your doctor, becomes involved in your care by providing assistance with your health care diagnosis or treatment.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you, such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization re-view activities. For example, obtaining approval for procedures may require that your relevant protected health information be disclosed to the health plan to obtain approval for those services.

Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of this office. These activities may include but are not limited to quality assessment activities, employee review activities, and staff training.

For example, we may disclose your protected health information to interns or precepts that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your doctor. Communications between you and the doctor or his assistants may be recorded to assist us in accurately capturing your responses. We may also call you by name in the reception area when your doctor is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We will share your protected health information with third-party "Business Associates" that perform various activities (e.g., billing, transcription services for the practice). Whenever an arrangement between our office and a Business Associate involves the use or disclosure of your protected health information, we will have a written agreement with that Business Associate that contains terms that will protect the privacy of your protected health information.

We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also use and disclose your protected health information for other internal marketing activities. We may also send you information about products or services that we believe may be beneficial to you. You may request that these materials not be sent to you.

Other uses and disclosures of your protected health information will be made only with your written authorization unless otherwise permitted or required by law as described below.

For example, with your written, signed authorization, we may use your demographic information and the dates that you received treatment from our office, as necessary, in order to contact you for fundraising activities supported by our office.

You may revoke any of these authorizations, at any time, in writing, except to the extent that your doctor or the practice has taken an action in reliance on the use or disclosure indicated in the authorization.

In the following instance where we may use and disclose your protected health information, you have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your doctor may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.

Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend, or any other person you identify your protected health information that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative, or any other person that is responsible for the care of your location or general condition. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

We may use or disclose your protected health information in the following situations without your consent or authorization. These situations include:

Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.

Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury, or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.

Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.

Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect, or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful processes.

Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (I) legal process and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the Practice, and (6) medical emergency (not on the Practice's premises) and it is likely that a crime has occurred.

Workers' Compensation: We may disclose your protected health information, as authorized, to comply with workers' compensation laws and other similar legally-established programs.

Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.

Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A "designated record set" contains medical and billing records and any other records that your doctor and the Practice uses for making decisions about you.

Under Federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewed. In some circumstances, you may have a right to have this decision reviewed. Please ask your doctor if you have questions about access to your medical record.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must be in writing and state the specific restriction requested and to whom you want the restriction to apply.

Your provider is not required to agree to a restriction that you may request. If the doctor believes it is in your best interest to permit the use and disclosure of your protected health information, your protected health information will not be restricted. If your doctor does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your doctor.

You may request a restriction by presenting your request, in writing to a staff member in our office. The staff member will provide you with the "Restriction of Consent" form. Complete the form, sign it, and ask that the staff member provide you with a photocopy of your request initialed by them. This copy will serve as your receipt.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other methods of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing.

You may have the right to have your doctor amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please ask your doctor if you have questions about amending your medical record.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment, or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, to family members or friends involved in your care, pursuant to a duly executed authorization or for notification purposes. The right to receive this information is subject to certain exceptions, restrictions, and limits.

You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

 

You may complain to us, to the Texas Attorney General’s Office, or the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint.

Our Privacy Officer is Jim Moore, a Certified HIPAA Professional. You may contact our Privacy Officer in writing at our office address or by calling 469.342.8300, Extension 508. Our website may offer additional information about the complaint process.

This notice was published and becomes effective on March 15, 2017

Phase I (Interceptive Treatment)/ Phase II (Full Braces) / Invisalign

Hebron smiles (dentist) hereby agrees to provide the agreed-upon orthodontic services, such as: consultation, diagnosis, insertion of braces (as necessary), treatment plan, subsequent adjustments, and providing of other appliances (as needed); I set of retainers is included. Retainer types are determined on a case basis.

Extended treatment Terms

- If treatment should extend 6 months past estimated treatment, additional monthly payments will be required. The patient understands the amount of time necessary to complete treatment cannot be determined with certainty. Many factors affect treatment estimation. Some of those factors include the patient’s facial growth pattern, muscle habits – tongue thrusting, finger sucking, and mouth breathing. Additionally, patient cooperation, compliance with instruction, keeping appointment, wearing elastic, appliances, broken appliances and broken brackets may length of treatment.

Additional Charges

- After 5 occurrences of broken brackets or bands - $25
- Records requested by an external dental office or by the patient for a personal copy, will be billed at $75.
- Other items such as permanent retainers, night guards, spaces maintainers, lost appliances.
- General dental treatment, including but not limited to: extraction, cleaning, and filling.

Treatment Time

- Treatment time is an estimate, not an exact science, In the event treatment is completed in less than the estimated time monthly payments will continue until the payment terms of the finance contract are fulfilled. Monthly payments do not correlate to treatment months, months, and are considered a separate agreement.

Discontinuing Treatment

- If the patient transfers out or discontinues treatment during the contracted orthodontic period, the financial contract will be pro-rated as follows:

1. Twenty five (25%) of the contracted fee after bonding has been performed'
2. Monthly payment equal to the amount in your fiancé contract for each month of treatment.
3. The remaining amount will be credited to the patient.
   
   

- If the patient elects to discontinue treatment and requests removal of braces, a de-band fee of $150 will apply.

Appointments

- Appointments should be kept regularly, as directed by the dentist.
- The patient is responsible for all appointments and visits required to complete treatment.
- Missed or broken appointments can add to the length of treatment.
- Some appointments must be made at specific times, for certain orthodontic procedures because of the length of time and nature of procedure. We will try to accommodate school, work, or other conflicting schedules as much as possible.

Insurance

- Insurance claims will be billed for your convenience.
- If for any reason insurance does not pay their estimated mount, the patient becomes responsible for the remaining balance.
- This include loss of benefits or coverage, delay in payments (60 days) , or pre-determinations.
- Insurance estimates are not a guarantee of payment.
- Benefit elections are not a guarantee of payment.
- Benefit elections are handled between you, your insurance company, and your employer
- If your benefit were based on discounted fees or a discount off our usual fee and coverage is lost, your account will be recalculated based on our current cash pricing, or new benefits will be considered.

Compliance

- The patient agrees to have their teeth cleaned and examined by a general dentist every 3-6 months during treatment.
- Regular appointments are necessary to advance treatment, if the patient fails to show for 3 consecutive appointments, we will assume the patient has elected to discontinue treatment, and will be dismissed from the practice. If the patient chooses to restart treatment, a $150 charge will apply plus any outstanding balance.

The dentist at any time may require an orthodontic re- consultation appointment. The patient will be required to be present at this visit if the patient is a minor. The dentist will evaluate the progress of treatment and make sure the teeth and gums healthy. If necessary your braces may be removed, and you will be referred to the general dentist or other dental specialist for treatment. This is ensure that your teeth and gums remain healthy whole you were braces.

If necessary the dentist may discontinue treatment, and dismiss the patient from the practice if in their professional judgment the case cannot be completed successfully due to patient non-compliance or failure to cooperate.

Before beginning orthodontic treatment, you should be aware there are inherent risks and limitations. These are seldom enough to rule out treatment. but should be carefully considered before deciding to begin orthodontic treatment. Please note that it is impossible to list. Every possible circumstance and the following must be considered a patient list. Please read this consent carefully and ask for an explanation of any you do not understand. A certain amount should be expected when braces are put on and at each wire change.