The information that I have given is correct, to the best of my knowledge. I understand that it is my responsibility to inform this office of any changes in my / my child's medical or dental status.
Before treatment is rendered, adequate radiographs of the teeth and mouth must be taken. I authorize and give consent to perform dental services agreed between doctor and patient and/or parent or guardian to be necessary or advisable including the use of local anesthesia and other medication as indicated.
Payments for all treatments and services are my responsibility.
This notice describes how your medical information may be used and disclosed, and how you can receive this information. Please review it carefully.
Alan Slootsky, D.M.D., M.A.G.D., Restorative & Implant Dentistry, hereafter referred to as “Practice,” is committed to preserving the privacy and confidentiality of your health information. This Notice of Privacy Practices describes how we may use and disclose your protected health information, hereafter referred to as “PHI,” to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. 45 CFR§ 164.520. This Notice has been revised to conform to HIPAA’s Final Rule referred to as the “Omnibus Rule” published 01/25/13. This notice replaces previous versions of the Notice and is effective 09/23/2013. You may access or obtain a copy according to the following options: 1) our website at restorativeandimplantdentistry.com 2) contact the office and request a copy to be sent to you by mail or email, 3) request a copy at the time of your next appointment.
How We Use Your Information: Your PHI may be used and disclosed by our Practice’s provider, administrative and or clinical staff and others outside of our Practice who are involved in your care and treatment for the purpose of providing healthcare services to you.
We will use and disclose your PHI to provide, coordinate or manage your care and any related services. We may disclose PHI to other providers who may be treating you such as a specialist.
We will use your PHI to obtain payment for the services provided by this Practice. For example, if we are working with your insurance plan, we may verify eligibility or coverage for benefit determination. We may use or disclose your information so that a bill may be sent to you that may include services provided.
C) Healthcare Operations:
The Practice may use or disclose, as needed, your PHI in order to support its business activities such as quality performance reviews regarding our services or the performance of our staff.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object:
We may use or disclose your PHI in the following situations without your authorization or providing you the opportunity to agree or object as follows:
D) Required or Permitted by Law:
We may use or disclose your PHI as required by law. This may include public health activities such as controlling a communicable disease or compliance with health oversight agencies authorized by law. We may disclose PHI to a public health authority authorized to receive reports of child abuse or neglect. We may disclose your PHI if we believe you have been a victim of abuse, neglect or domestic violence to a governmental agency authorized to receive such information in compliance with state and federal law. We may disclose your PHI to the Food and Drug Administration for the quality, safety, or effectiveness of FDA-regulated products or activities. We may disclose your PHI in the course of a legal proceeding in response to a subpoena, discovery request or other lawful process. We may also disclose PHI to law enforcement providing applicable legal requirements are satisfied. We may disclose PHI to a coroner or medical examiner for identification purposes. We may disclose PHI to researchers when the information does not directly identify you as the source of the information and such research has been approved by an institutional review board to ensure the privacy of the PHI. We may disclose PHI as authorized to comply with workers’ compensation laws. We may use and disclose your PHI if you are an inmate of a correctional facility and this information is necessary for your care.
Authorization for Other Uses and Disclosures of PHI: Use and disclosure of your PHI not addressed in this Notice of Privacy Practices will be made only with your written authorization. You may revoke this authorization in writing at any time. If you revoke this authorization, we will no longer use or disclose your PHI; however, we are unable to retrieve previous disclosures made with your prior authorization.
Other Permitted and Required Uses and Disclosures that Require Your Permission or Objection:
The following is a statement of your rights regarding PHI we gather about you:
A) Copy of this Notice:
You have the right to a copy of this notice including a paper copy.
B) Inspect and Copy PHI:
You have the right to inspect and obtain a copy of PHI about you maintained by our Practice to include patient and billing records. You must submit a written request and indicate whether you prefer a paper or electronic copy. According to state and federal law, we may charge you a reasonable fee to copy your records. Our Practice does not transmit unsecure PHI via email. However, if you prefer this information emailed to you with encryption or security measures, we will comply with your request and will verify your email address. We suggest sending our Practice an email and we will reply with the attachment. (Note: Under federal law, you may not inspect or copy psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding. Please contact the Privacy Officer for more details).
You have the right to have your provider amend your PHI about you in a designated record set. Please consult with the Privacy Officer. We may deny this request and you may respond with a statement. We may include a rebuttal statement in your record. Reasons we may deny amending such information, but not limited to these reasons, is if we did not create the information, or if the individual who created the information is no longer available to make the amendment or it is not part of the information maintained at our Practice.
You have the right to request a restriction of your PHI. If you paid out-of-pocket for a service or item, you have the right to request that information not be disclosed to a health plan for purposes of payment or health care operations and we are required to honor that request. You may request in writing to our Privacy Officer not to use or disclose any part of your PHI for the purposes of treatment, payment or health care operations such as to family members or friends involved in your care or for notification purposes as described in this Notice of Privacy Practices. However, your provider is not required to agree to this restriction. You may discuss restrictions with the Privacy Officer.
E) Confidential Communications:
You have the right to request to receive confidential communications from our Practice by alternative means or at an alternative location. For example, you may prefer our Practice to use your mobile telephone or email rather than a residential line. Please make this request in writing to the Privacy Officer. Our staff will not ask personal questions regarding your request.
You have the right to request an accounting of disclosures of your PHI including those made through a Business Associate as set forth in CFR 45 § 164.528. The HITECH Act removed the accounting of disclosures exception to PHI to carry out treatment, payment and healthcare operations if such disclosures are made through the EHR. To request an accounting, you must submit your request in writing to the Privacy Officer.
G) Breach Notification:
According to the HITECH Act, you have the right to be notified following a breach of unsecured PHI that affects you. “Unsecured” is information that is not secured through the use of technology or methodology identified by the Secretary of the U.S. Department of Health and Human Services to render the PHI unusable, unreadable and undecipherable to unauthorized users. Breach notification applies to our Business Associates who are obligated to notify our Practice if a breach of unsecured PHI occurs that affects you.
If PHI is used for fundraising which is considered “health care operations,” basic requirements must be satisfied to include notice to the individual and a process for individuals to opt-out. If the individual consents, only specific parts of PHI may be used for fundraising. Note: Your PHI will not be used in this manner at our Practice.
You have the right to file a complaint if you believe your privacy rights or that of another individuals’ have been violated. You may contact our Privacy Officer and your issue will be addressed. You may also file a complaint with the Secretary of Health and Human Services at: U.S. Department of Health & Human Services, Office of Civil Rights, 200 Independence Avenue, SW, Washington, D.C. 20201. Your complaint must be filed in writing, either on paper or electronically, by mail, fax, or e-mail; name the covered entity or business associate involved and describe the acts or omissions you believe violated the requirements of the Privacy, Security, or Breach Notification Rules; and be filed within 180 days of when you knew that the act or omission complained of occurred. You may visit the Office of Civil Rights website at www.hhs.gov/ocr/hipaa/ for more information.
If you have any questions, would like additional information or want to report a problem regarding the handling of your PHI, you may contact the Privacy Officer at:
Alan Slootsky D.M.D., M.A.G.D.Restorative & Implant Dentistry161 S. Pompano ParkwayPompano, Florida 33069TEL: (954) 972-1000FAX: (954) 972-1889
You will not be penalized for filing a complaint.
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
I acknowledge receiving the practice's "Notice of Privacy Practices" dated 3/5/2021.
Please list authorized persons with whom we may discuss your Protected Health Information (PHI) in additional to custodial parents and/or legal guardians.
I have signed the Notice of Privacy Practices of Alan Slootsky D.M.D. PA. I hereby authorize, as indicated by my signature below, Alan Slootsky D.M.D. PA. to use and to disclose my protected health information for any necessary clinical, financial, and insurance purposes, as authorized in the Patient Consent Form.
In consideration of my engagement as a model, upon the terms herewith stated, I hereby give to Alan Slootsky DMD PA, legal representatives and assigns, those for whom Alan Slootsky DMD PA is acting, and those acting with his/her authority and permission:
A) The unrestricted right and permission to copyright and use, re-use, publish, and republish photographic portraits or pictures of me or in which I may be included intact or in part, composite or distorted in character or form, without restriction as to changes or transformations in conjunction with my own or a fictitious name, or reproduction hereof in color or otherwise, made through any and all media now or hereafter known for illustration, art, promotion, advertising, trade, or any other purpose whatsoever.
B) I also permit the use of any printed material in connection therewith.
C) I hereby relinquish any right that I may have to examine or approve the completed product or products or the advertising copy or printed matter that may be used in conjunction there-with or the use to which it may be applied.
D) I hereby release, discharge and agree to save harmless Alan Slootsky DMD PA, legal representatives or assigns, and all persons functioning under his/her permission or authority, or those for whom he/she is functioning, from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form whether intentional or otherwise, that may occur or be produced in the taking of said picture or in any subsequent processing thereof, as well as any publication thereof, including without limitation any claims for libel or invasion of privacy.
E) I hereby affirm that I am over the age of majority and have the right to contract in my own name or contract for the minor listed below who will appear in the photo shoot. I have read the above authorization, release and agreement, prior to its execution; I fully understand the contents thereof. This agreement shall be binding upon me and my heirs, legal representatives and assigns.
You the patient have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment.
Do not consent to treatment unless and until you discuss potential benefits, risks, and complications with your dentist and all of your questions are answered. By consenting to treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the probability of occurrence.
It is very important that you provide your dentist with accurate information before, during and after treatment. It is equally important that you follow your dentist's advice and recommendations regarding medication, pre and post treatment instructions, referrals to other dentists or specialists, and return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome.
As with all surgery, there are commonly known risks and potential complications associated with dental treatment. No one can guarantee the success of the recommended treatment, or that you will not experience a complication or less than optimal result. Even though many of these complications are rare, they can and do occur occasionally.
Some of the more commonly known risks and complications of treatment include, but are not limited to the following:
This form is intended to provide you with an overview of potential risks and complications. Do not sign this form or agreement to treatment until you have read, understood, and accepted each paragraph stated above. Please discuss the potential benefits, risks, and complications of recommended treatment with your dentist. Be certain all of your concerns have been addressed to your satisfaction by your dentist before commencing treatment.
I understand that my dental treatment may require the use of a local anesthetic for pain control. I understand that a local anesthetic may consist of different medications that are injected into the cheek or gum area. These drugs may include prilocaine, mepivacaine, bupivacine, articaine, or others. Many people refer to local injections as "Novocaine", however this particular drug is seldom used because newer medications are more effective, longer lasting and less likely to cause allergic problems. I understand that local anesthetics may contain a ''vasoconstrictor" like epinephrine; antioxidants, such as sulfites or methylparaben for preservation of the solutions; sodium hydroxide, and sodium chloride.
I understand that local anesthetics will cause a section of my mouth to become numb, with the numbness lasting from a few minutes to several hours. I know that while my mouth is numb I must be careful not to bite my lips or tongue.
Local anesthetics are among the most common drugs used in a dental office. Complications and side effects are rare, but may include, among others not listed on this sheet:
I understand that if I have uncontrolled high blood pressure, uncontrolled thyroid problems, agina, or have recently had a heart attack that I will inform my dentist without fail as these conditions have caused complications for persons receiving local anesthesia. I will also inform the dentist of any prescription or over-the-counter medications I am taking as these may interact with local anesthetics.
I understand the recommendation of local anesthetic for my treatment, any fee involved, risks of treatment, any alternatives and risks of these alternatives, including consequences of doing nothing. I have had all of my questions answered, and have not been offered any guarantees.