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THIS NOTICE DESCRIBES HOW DENTAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOWYOU CAN GET ACCESS TO THIS INFORMATION.PLEASE REVIEW IT CAREFULLY.
We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information. We make a record of the medical care we provide and may receive such records from others. We use these records to provide or enable other health care providers to provide quality medical care, to obtain payment for services provided to you as allowed by your health plan and to enable us to meet our professional and legal obligations to operate this medical practice properly. We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. This notice describes how we may use and disclose your medical information. It also describe your rights and our legal obligations with respect to your medical information. If you have any questions about this Notice, please contact our Privacy Officer listed above.
A. How This Dental Practice May Use or Disclose Your Health Information
This dental practice collects health information about you and stores it in a chart and/or on a computer and in electronic health record/personal health record. This is your dental record. The dental record is the property of this dental practice; but the information in the medical record belongs to you. The law permits us to use or disclose your health information for the following purposes:
1. Treatment. We use medical information about you to provide your medical care. We disclose medical information to our employees and others who are involved in providing the care you need. For example, we may share your medical information with other physicians or other health care providers who will provide services that we do not provide. Or we may share this information with a pharmacist who needs it to dispense a prescription to you, or a laboratory that performs a test. We may also disclose medical information to members of your family or others who can help you when you are sick or injured, or after you die.
2. Payment. We use and disclose medical information about you to obtain payment for the services we provide. For example, we give your health plan the information it requires before it will pay us. We may also disclose information to other health care providers to assist them in obtaining payment for services they have provided to you.
3. Health Care Operations. We may use and disclose medical information about you to operate this medical practice. For example, we may use and disclose this information to review and improve the quality of care we provide, or the competence and qualifications of our professional staff. Or we may use and disclose this information to get your dental plan to authorize services or referrals. We may also use and disclose this information as necessary for medical reviews, legal services and audits,including fraud and abuse detection and compliance programs and business planning and management. We may also share your medical information with our "business associates," such as our billing service, that perform administrative services for us. We have a written contract with each of these business associates that contains terms requiring them and their subcontractors to protect the confidentiality and security of your protected health information. We may also share your information with other health care providers, health care clearinghouses or dental plans that have a relationship with you, when they request this information to help them with their qualify assessment and improvement activities, their patient-safety activities, their population-based efforts to improve health or reduce health care costs, their protocol development,case management or care-coordination activities, their review of competence, qualifications and performance of health care professionals, their training programs, their accreditation, certification or licensing activities, or their health care fraud and abuse detection and compliance efforts.
4. Appointment Reminders. We may use and disclose medical information to contact and remind you about appointments. If you are not home, we may leave this information on your answering machine or in a message left with the person answering the phone.
5. Sign In Sheet. We may use and disclose medical information about you by having you sign in when you arrive at our office. We may also call out your name when we are ready to see you.
6. Notification and Communication With Family. We may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location, your general condition or, unless you had instructed us otherwise, in the event of your death. In the event of a disaster, we may disclose information to a relief organization so that they may coordinate these notification efforts. We may also disclose information to someone who is involved with your care or helps pay for your care. If you are able and available to agree or object, we will give you the opportunity to object prior to making these disclosures, although we may disclose this information in a disaster even over your objection if we believe it is necessary to respond to the emergency circumstances. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.
7. Marketing. Provided we do not receive any payment for making these communications, we may contact you to give you information about products or services related to your treatment, case management or care coordination, or to direct or recommend other treatments, therapies, health care providers or settings or care that may be of interest to you. We may similarly describe products or services provided by this practice and tell you which health plans this practice participates in. We may also encourage you to maintain a healthy lifestyle and get recommended tests, participate in a disease management program, provide you wit small gifts, tell you about government sponsored health programs or encourage you to purchase a product or service when we see you, for which we may be paid. Finally, we may receive compensation, which covers our cost of reminding you to take and refill your medication, or otherwise communicate about a drug or biologic that is currently prescribed for you. We will not otherwise use or disclose your medical information for marketing purposes or accept any payment for other marketing communications without your prior written authorization. The authorization will disclose whether we receive any compensation for any marketing activity you authorize, and we will stop any future marketing activity to the extent you revoke that authorization.
8. Sale of Health Information. We will not sell your health information without your prior written authorization. The authorization will disclose that we will receive compensation for your health information if you authorize us to sell it, and we will stop any future sales of your information to the extent that you revoke that authorization.
9. Required by Law. As required by law, we will use and disclose your health information, but we will limit our use or disclosure to the relevant requirements of the law. When the law requires us to report abuse, neglect or domestic violence, or respond to judicial or administrative proceedings, or to law enforcement officials, we will further comply with the requirement set forth below concerning those activities.
10. Public Health. We may, and care sometimes required by law, to disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child, elder or dependent adult abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure. When we report suspected elder or dependent adult abuse or domestic violence, we will inform you or your personal representative promptly unless in our best professional judgment, we believe the notification would place you at risk of serious harm or would require informing a personal representative we believe is responsible for the abuse or harm.
11. Health Oversight Activities. We may, and are sometimes required by law, to disclose your health information to health oversight agencies during the course of audits, investigations, inspections, licensure and other proceedings, subject to the limitations imposed by law.
12. Judicial and Administrative Proceedings. We may, and are sometimes required by law, to disclose your health information in the course of any administrative or judicial proceeding to the extent expressly authorized by a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request or other lawful process if reasonable efforts have been made to notify you of the request and you have not objected, or if your objections have been resolved by a court or administrative order.
13. Law Enforcement. We may, and are sometimes required by law, to disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order, warrant, grand jury subpoena and other law enforcement purposes.
14. Coroners. We may, and are often required by law, to disclose your health information to coroners in connection with their investigations of deaths.
15. Organ or Tissue Donation. We may disclose your health information to organizations involved in procuring, banking or transplanting organs and tissues.
16. Public Safety. We may, and are sometimes required by law, to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.
17. Proof of Immunization. We will disclose proof of immunization to a school that is required to have it before admitting a student where you have agreed to the disclosure on behalf of yourself or your dependent.
18. Specialized Government Functions. We may disclose your health information for military or national security purposes or to correctional institutions or law enforcement officers that have you in their lawful custody.
19. Workers' Compensation. We may disclose your health information as necessary to comply with workers' compensation laws. For example, to the extent your care is covered by workers' compensation. we will make periodic reports to your employer about your condition. We are also required by law to report cases of occupational injury or occupational illness to the employer or workers' compensation insurer.
20. Change of Ownership. In the event that this medical practice is sold or merged with another organization, your health information/record will become the property of the new owner, although you will maintain the right to request that copies of your health information be transferred to another physician or medical group.
21. Breach Notification. In the case of a breach of unsecured protected health information, we will notify you as required by law. If you have provided us with a current e-mail address, we may use e-mail to communicate information related to the breach. In some circumstances our business associate may provide the notification. We may also provide notification by other methods as appropriate [Note: Only use e-mail notification if you are certain it will not contain PHI and it will not disclose inappropriate information. For example if your e-mail address is "digestivediseaseassociates.com" an e-mail sent with this address could, if intercepted, identify the patient and their condition.]
22. Research. We may disclose your health information to researchers conducting research with respect to which your written authorization is not required as approved by an Institutional Review Board or privacy board, in compliance with governing law.
B. When This Medical Practice May Not Use or Disclose Your Health Information
Except as described in this Notice of Privacy Practices, this medical practice will, consistent with its legal obligations, not use ordisclose health information which identifies you without your written authorization. If you do authorize this medical practice to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.
C. Your Health Information Rights
1. Right to Request Special Privacy Protections. You have the right to request restrictions on certain uses and disclosures of your health information by a written request specifying what information you want to limit, and what limitations on our use or disclosure of that information you wish to have imposed. If you tell us not to disclose information to your commercial health plan concerning health care items or services information for treatment or legal reasons. We reserve the right to accept or reject any other request, and will notify you of our decision.
2. Right to Request Confidential Communications. You have the right to request that you receive your health information in a specific way or at a specific location. For example, you may ask that we send information to a particular e-mail account or to your work address. We will comply with all reasonable requests submitted in writing which specify how or where you wish to receive these communications.
3. Right to Inspect and Copy. You have the right to inspect and copy your health information, with limited exceptions. To access your medical information, you must submit a written request detailing what information you want access to, whether you want to inspect it or get a copy of it, and if you want a copy, your preferred form and format. We will provide copies in your requested form and format if it is readily producible, or we will provide you with an alternative format you find acceptable, or if we can't agree and we maintain the record in an electronic format, you choice of a readable electronic or hard copy format. We will also send a copy to any other person you designate in writing. We will charge a reasonable fee which covers our costs for labor, supplies, postage, and if requested and agreed to in advance, the cost of preparing an explanation or summary. We may deny your request under limited circumstances. If we deny your request to access your child's records or the records of an incapacitated adult you are representing because we believe allowing access would be reasonably likely to cause substantial harm to the patient, you will have a right to appeal our decision. If we deny your request to access your psychotherapy notes, you will have the right to have them transferred to another mental health professional.
4. Right to Amend or Supplement. You have a right to request that we amend your health information that you believe is incorrect or incomplete. You must make a request to amend in writing, and include the reasons you believe the information is inaccurate or incomplete. We are not required to change your health information, and will provide you with information about this medical practice's denial and how you can disagree with the denial. We may deny your request if we do not have the information, if we did not create the information (unless the person or entity that created the information is no longer available to make the amendment), if you would not be permitted to inspect or copy the information at issue, or if the information is accurate and complete as is. If we deny your request, you may submit a written statement of your disagreement with that decision, and we may, in turn prepare a written rebuttal. All information related to any request to amend will be maintained and disclosed in conjunction with any subsequent disclosure of the disputed information.
5. Right to an Accounting of Disclosures. You have a right to receive an accounting of disclosures of your health information made by this medical practice, except that this medical practice does not have to account for the disclosures provided to you or pursuant to your written authorization, or as described in paragraphs 1(treatment), 2(payment), 3(health care operations), 6(notification and communication with family) and 18(specialized government functions) of Section A of this Notice of Privacy Practices or disclosures for purposes of research or public health which exclude direct patient identifiers, or which are incident to a use or disclosure otherwise permitted or authorized by law, or the disclosures to a health oversight agency or law enforcement official to the extent this medical practice has received notice from that agency or official that providing this accounting would be reasonably likely to impede their activities.
6. Right to Paper or Electronic Copy of this Notice. You have a right to notice of our legal duties and privacy practices with respect to your health information, including a right to a paper copy of this Notice of Privacy Practices, even if you have previously requested its receipt by e-mail.
If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact our Privacy Officer listed at the top of this Notice of Privacy Practices.
D. Changes to this Notice of Privacy Practices
We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made we are required by law to comply with the terms of this Notice currently in effect. After an amendment is made, the revised Notice of Privacy Protections will apply to all protected health information that we maintain, regardless of when it was created or received. We will keep a copy of the current notice posted in our reception area, and a copy will be available at each appointment. We will also post a current notice on our website.
Complaints about this Notice of Privacy Practices or how this medical practice handles your health information should be directed to our Privacy Officer listed at the top of this Notice of Privacy Practices. If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:
Region - Dallas (Arkansas, Louisiana, New Mexico, Oklahoma, Texas)Jorge Lozano, Regional ManagerOffice for Civil RightsU.S. Department of Health and Human Services1301 Young Street, Suite 1169 Dallas, TX 75202Voice Phone (800) 368-1019FAX (214) 767-0432TDD (800) 537-7697OCRMail@hhs.gove
The complaint form may be found at www.hhs.gov/ocr/privacy/hippa/complaints/hipcomplaint.pdfYou will not be penalized in any way for filling a complaint.
** Please Note: It is your right to refuse to sign this Acknowledgement. **
This consent form allows Hebron Smiles to use and disclose information about me protected under the Health Insurance Portability and Accountability Act of 1996. This information may be used or disclosed to carry out treatment, payment or health care operations.
Hebron Smiles has proveded me with a Notice of Privacy Practices, which more completely describes such uses and disclosures. It provided this notice prior to my signing this form in accordance with my right to review its practices before signing consent.
Thank you for choosing Hebron Smiles. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.
You choose from:
Cash, Check, Visa, MasterCard, American Express or Discover Card
Convenient Monthly Payment Options from CareCredit Healthcare & Lending Club Financial:
Please initial that you have read and understand the following:
If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need.
Phase I (Interceptive Treatment)/ Phase II (Full Braces)/ Invisalign
Hebron smiles (orthodontist) 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.
- 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 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.
- If the patient transfers out or discontinues treatment during the contracted orthodontic period, the financial contract will be pro-rated as follows:
- If the patient elects to discontinue treatment and requests removal of braces, a de-band fee of $150 will apply.
- Appointments should be kept regularly, as directed by the orthodontist.- 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 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.
- 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 orthodontist 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 orthodontist 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 orthodontist 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.
The doctor has recommended aligners for your orthodontic treatment, before beginning any 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 partial list. Please read this consent carefully and ask for an explanation of anything you do not understand.
What are Orthodontic Aligners?
Aligner treatment consists of a sequence of clear plastic (or similar material), removable appliance that progressively move your teeth. The aligners are treatment planned and fabricated based on your doctor’s expert diagnosis and prescription joined with state-of-the-art imaging software that indicates the ideal movements of your teeth during the course of treatment. Upon approval of the treat mentation developed by your doctor, the sequence of customized appliance is constructed exclusively for your treatment.
What is the Aligner Process?
To determine your orthodontic treatment plan, your doctor will perform a routine orthodontic examination to include x-rays, photographs, and a pano/ceph radiograph. Your doctor will take impressions of your upper and lower teeth to fabricate models to be utilized to create your treatment plan. The models will be sent to a lab for scanning and imaging. The lab technician will follow the doctor’s prescription to create a software model of your recommended treatment plan. Upon approval of the treatment plan, a sequence of aligner appliances will be fabricated and delivered to your doctor’s office.
The total count of appliance and length of treatment will vary depending on the complexity of your treatment plan. Your doctor will deliver aligners with specific instructions for use and home care. Each aligner must be worn continuously, only to be removed for eating, brushing, or flossing of teeth. Wear time should equate to 20-22 hours per day.
Your doctor will prescribe and instruct you when to switch to the next aligner every 2-3 weeks. The time will vary based on your treatment complexity, wear time compliance, and your doctor’s direction. Unless otherwise instructed , you will be scheduled to see your doctor every 6 to 8 weeks. Some patients may require additional services during the course of treatment. This may include but is not limited to bonded aesthetic attachments, use of elastics to facilitate movement, additional impressions, and aligners to refine treatment.
What are the Benefits of Aligners?
- Clear aligners offer a cosmetic alternative to traditional braces- Aligners are clear and nearly undetectable.- Utilizing the imaging software allows doctor and patient to visually review the treatment plan.- Normal brushing and flossing unlike traditional braces.- There are no wires and brackets
What are Risks and Inconveniences Associated with Aligners?
- Failure to wear appliance the necessary hours per day and or as directed by your doctor, not using appliance as intended, missing follow up appointments, erupting or atypically shaped teeth could extend treatment time or affect the desired result and outcome of treatment.- Tooth tenderness or plan may occur after switching to the aligner next in the sequence.- Appliance may irritate or scratch gums, cheeks, and lips.- Teeth may move or shift after treatment. You will be provided retainers, with consistent wear replace risk will be reduced.- Tooth decay, periodontal (gum) disease, inflammation or decalcification (permanent marking) may occur if sugary food and drinks are consumed, if appliance are worn without proper brushing and flossing, or if appropriate oral hygienic and preventive care by the dentist is not maintained.- Aligner appliances may temporally affect speech or cause a lisp while getting used to appliance.- Aligner appliances may cause ort-term increase in salve or dry mouth. Certain medications may impact this effect.- Attachments may be bonded (glued) to one or more teeth to expedite tooth movement and/or appliance retention.- Teeth may require interproximal re-contouring or slenderizing to provide space for tooth movement and alignment.- Dental bite may change during the course of treatment and may result in short-term discomfort.- Once treatment is complete, the dental bite may require adjustment.- Supplemental or additional orthodontic treatment may be required to achieve desired result. This may include but is not limited to bonded buttons, orthodontic elastics, supplementary appliance/devices, restorative dental procedures for more complex treatment plans.- Teeth that have overlapped for long periods of time may be missing gingival (gum) tissue, which may result in the appearance of a dark space/triangle.- Aligner appliance are not effective in the movement of dental implants.- Medical conditions and use of medications can affect orthodontic treatment.- Health of the bone and gums which support teeth may be impacted or aggravated.- Sometimes oral surgery is necessary to correct severe jaw imbalances. If they are present prior to stating orthodontic treatment, the patient will be referred to the proper specialist for surgery and orthodontic treatment.- Tooth or teeth that have been injured, traumatized, or have had significant restoration may be aggravated. In rare cases the longevity of the tooth may be reduced or may require additional dental treatment. Treatment could include but is not limited to root canal, dental restoration, or extraction.- Existing dental restorations (e.g. fillings or crowns) can become dislodged or lose and require replacement and / or re-cementation.- Short clinical crowns (short teeth) may present appliance retention complications that can hinder tooth movement.- Root length may be shortened during orthodontic treatments which may reduce tooth longevity.- Aligner breakage is more likely in patients with severe crowding or missing teeth.- Appliance and/or its parts can become broken or dislodged and can be accidentally swallowed or aspirated.- In rare cases, problems may occur with the jaw joint causing pain, headaches or ear problems- Allergic reactions may occur.- Teeth that are not converted by the appliance may continue to erupt.