Welcome to Magnolia Family Dental, where our mission is to enhance the lives of our patients through superior care and treatment that is consistent with our values and vision.  We are dedicated to delivering comprehensive dental care of exceptional value that can dramatically improve not only our patients' smiles but also their health, happiness, and quality of life.  We pride ourselves on our patient-centered practice, where we perform the highest level of care and service in a clean and well-organized environment.

All recommended treatments are in the best interest of our patients.  We will not allow your dental insurance to dictate your treatment plan; therefore we will inform you before we perform any recommended treatment.

DENTAL INSURANCE:

If you have dental insurance, please be aware that IT IS AN ESTIMATE ONLY.  Coverage may be different if your deductible has not been met, annual maximum has been met, or if your coverage has additional limitations and exclusions.  All estimated co-pays and deductibles are due at the time of service.

As a courtesy to our patients, we are happy to submit your claims for services.  In order for us to do this, you must provide us with accurate and up-to-date insurance information.  We will verify your coverage and plan before your appointment.  With this, we will estimate the insurance portion and your co-insurance.  This may or may not be what the insurance will actually pay.  We'll do our best to help you receive your maximum benefits.  Patients are responsible for all balances incurred for services received.  A late fee of 1.6% will be assessed to monthly to accounts after 60 days.  Any unpaid balance over 90 days will be considered delinquent and turned over to a collection agency. Fees may apply.

We will wait 45 days for claims to be paid. After 45 days if payment has not been made, you will be asked to pay the balance and seek reimbursement from your insurance company.

CANCELLATION/BROKEN APPOINTMENT POLICY

Dental treatment that is planned for you is specific to you.  It is important for you to keep the scheduled dates and times to properly complete your treatment in the desired length of time.  A broken appointment is a loss to three people--- the patient who missed the valuable time, the patient who could have taken the valuable time, and the doctor who was fully staffed and prepared for the appointment.

I hereby agree to show up for my scheduled appointments on time and to give a 24 hour notice if I need to cancel or reschedule and appointment.  $25 fee may be assessed to your account.

Note: All cancellation fees must be paid prior to scheduling another appointment.

 

PREFERRED METHOD OF PAYMENT

All services must be paid at the time of service.  For your convenience, we accept cash, bankcards and all major credit cards- American Express, Visa, Discover and Mastercard.  We also offer a revolving line of credit through a third party CareCredit (upon credit approval).

The parent or guardian that brings in a minor for treatment is the financially responsible party.

 

I have read the above Financial Policy and understand that I am financially responsible for all charges, whether or not they are paid by my insurance.

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.  THE PRIVACY OF YOUR HEALTH IS IMPORTANT TO US.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information.  We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information.  We must follow the privacy practices that are described in this Notice while it is in effect.  This Notice takes effect 03/18/2022 and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes.  Before we make a sgnificant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time.  For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

 

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for your treatment, payment and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use or disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your helath 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.

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.  If you give us an authorization, you may revoke it in writing at any time.  Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.  Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient rights section of this Notice.  We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree to that we may do so.

Persons Involved in Care:  We may use or disclose health information to notify, or assist in the notification of (including indentifying or locating) a family member , your personal representative or another person responsible for your care, of your location, your general condition, or death.  If you are present, then prior to use or disclosure of your health information, we will provide you with any opportunity to object to such disclosures.  In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare.  We will also use our professional judgement and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Marketin Health-Related Services:  We will not use your health information for marketing communications with out your written authorization.

Required by Law:  We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect:  We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect or domestic violence or the possible victim of other crimes. We may use your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorites the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities.  We may disclose to correctional institution or law enforcement officials having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards or letters.)

PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies.  We will use the format you request unless we cannot practicably do so.  (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice.  We will charge you a reasonable cost based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $0 for each page and $1 per hour for staff time to copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)

Disclosure Accounting:  You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations and certain other activities, for the last 6 years.  If you request this accounting more than once in a 12 month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction:  You have the right to request that we place additional restrictions on our use or disclosure of your health information.  We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication:  You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.)  Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled unde the alternative means or location you request.

Amendment:  You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our website or by electronic mail (email), you are entitled to receive this Notice in written form.

 

                                                                                                                       

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at an alternative location, you may complain to us using the contact information listed at the end of this Notice.  You may also submit a written complaint to the U.S. Department of Health and Human Services.  We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

 

Contact Officer: Dr, Angela Marteeny, DDS

Telephone:713-526-4576

Email: magnolia@magnoliaofalvin.com

Address: 535 Tovrea Rd, Ste 104, Alvin, TX 77511

I had the opportunity to review and/or obtain a copy of this office’s Notice of Privacy Practices.

* You May Refuse to Sign This Acknowledgment*