All health information above is true and accurate to the best of my knowledge.
Cancellation and No-Show Policy
Any cancellations with less than a week notice, can be very difficult to fill if not impossible. We greatly appreciate a one weeks notice to change your appointment.
If you fail to show up to your appointment, there is a fee of $50 per hour scheduled.
Emergencies do not count against you, we understand that life happens and medical or family emergencies do not incur a fee under our policy.
Late Policy: If you arrive 15 min late to your appointment, we may need to reschedule you in order to have the proper amount time to see you.
We do not want finances to be an issue for our patients. We provide an array of financial options to make dental care more affordable. These are our options:
1. With insurance - we will file a claim on your behalf. Once the insurance pays, we will send you a statement of any balance you may owe us. Please pay within a week of receiving the statement.
2. No insurance Options:
a. Payment is due at the beginning or end of your appointment.
b. Care Credit - they can offer 6-12 month no interest payments.
c. 3 or 6 month payment plan, with automatic payments each month
3. Glow Family Dental Membership plan - for patients with no insurance. Full details available on GlowFamilyDental.com
Bounced checks will incur a $25 service charge.
I assign directly to Glow Family Dental all insurance benefits, otherwise payable to me for services rendered. I authorize and release information and payment of my dental benefits directly to the practice. I understand that I am financially responsible for all charges wether or not paid by insurance.
The practice may use my healthcare informationa nd may disclose such information to the insurance company or any referring doctors. I have read and fully understand my financial options and obligations.
If my account becomes delinquent, I understand that I am responsible for any collections, legal fees, and any other charges incurred to collect this account.
Finally, by signing this form I authorize Glow Family Dental to process credit card transactions initiated by me either by mail, phone, or text
In order to help remind you of your dental appointment as they are often scheduled months in advance we do the following:
a. When an appointment is first made you will get a reminder card or text.
b. One week before your appointment you will get a call or text. Please respond so that we know to keep that spot open for you.
c. One day before your appointment you will get a call or text.
Please Remember: The most important time we contact you, is one week before your appointment. This is the time to cancel or reschedule your appointment
Dr. Carlos M. Martinez
Glow Family Dental
This Notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Personally identifiable information about your health, your health care, and your payment for health care is called Protected Health Information (PHI). We must safeguard your PHI and give you this Notice about our privacy practices that explains how, when and why we may use or disclose your Protected Health Information. Except in the situations set out in the Notice, we must use or disclose only the minimum necessary Protected Health Information to carry out the use or disclosure.
We follow the practices described in this Notice, but we can change our privacy practices and the terms of this Notice at any time.
If we revise the Notice, you may read the new version of the Notice of Privacy Practices on our website at GlowFamilyDental.com at your convenience.
Uses and Disclosures of Your Protected Health Information That Do Not Require Your Consent. We may use and disclose your Protected Health Information as follows without your permission:
For treatment purposes. We may disclose your health information to doctors, nurses and others who provide your health care. For example, your information may be shared with people performing lab work or x-rays.
To obtain payment. We may disclose your health information in order to collect payment for your health care. For instance, we may release information to your insurance company.
For health care operations. We may use or disclose your health information in order to perform business functions like employee evaluations and improving the service we provide. We may use your information to contact you to remind you of your appointment or to call you by name in the waiting room when your doctor is ready to see you.
When required by law. We may be required to disclose your Protected Health Information to law enforcement officers, courts or government agencies. For example, we may have to report abuse, neglect or certain physical injuries.
For public health activities. We may be required to report your health information to government agencies to prevent or control disease or injury. We also may have to report work-related illnesses and injuries to your employer so that your workplace may be monitored for safety.
For health oversight activities. We may be required to disclose your health information to government agencies so that they can monitor or license health care providers such as doctors and nurses.
For activities related to death. We may be required to disclose your health information to coroners, medical examiners and funeral directors so that they can carry out duties related to your death, such as determining the cause of death or preparing your body for burial. We also may disclose your information to those involved with locating, storing or transplanting donor organs or tissue.
To avert a threat to health or safety. In order to avoid a serious threat to health or safety, we may disclose health information to law enforcement officers or other persons who might prevent or lessen that threat.
For specific government functions. In certain situations, we may disclose health information of military officers and veterans, to correctional facilities, to government benefit programs, and for national security reasons.
For workers' compensation purposes. We may disclose your health information to government authorities under workers' compensation laws.
Uses and Disclosures of Your Protected Health Information That Offer You an Opportunity to Object:
In the following situations, we may disclose some of your Protected Health Information if we first inform you about the disclosure and you do not object:
To your family, friends or others involved in your care. We may share with these people information related to their involvement in your care or information to notify them as to your location or general condition. We may release your health information to organizations handling disaster relief efforts.
Uses and Disclosures of Your Protected Health Information That Require Your Consent
The following uses and disclosures of your Protected Health Information will be made only with your written permission, which you may withdraw at any time:
For research purposes. In order to serve our patient community, we may want to use your health information in research studies. For example, researchers may want to see whether your treatment cured your illness. In such an instance, we will ask you to complete a form allowing us to use or disclose your information for research purposes. Completion of this form is completely voluntary and will have no effect on your treatment.
For marketing purposes. Without your permission, we will not send you mail or call you on the telephone in order to urge you to use a particular product or service, unless such a mailing or call is part of your treatment. Additionally, without your permission we will not sell or otherwise disclose your Protected Health Information to any person or company seeking to market its products or services to you.
For any other purposes not described in this Notice. Without your permission, we will not use or disclose your health information under any circumstances that are not described in this Notice.
You have the following rights related to your Protected Health Information:
To inspect/request a copy of your P.H.I. You may not view or copy information collected for use in a legal or government action, and information which you cannot access by law. If we use or maintain the requested information electronically, you may request that information in electronic format.
To request that we correct your Protected Health Information. If you think that there is a mistake or a gap in our file of your health information, you may ask us in writing to correct the file. We may deny your request if we find that the file is correct and complete, not created by us, or not allowed to be disclosed. If we deny your request, we will explain our reasons for the denial and your rights to have the request and denial and your written response added to your file. If we approve your request, we will change the file, report that change to you, and tell others that need to know about the change in your file.
To request a restriction on the use or disclosure of your Protected Health Information. You may ask us to limit how we use or disclose your information, but we generally do not have to agree to your request. An exception is that we must agree to a request not to send Protected Health Information to a health plan for purposes of payment or health care operations if you have paid in full for the related product or service. If we agree to all or part of your request, we will put our agreement in writing and obey it except in emergency situations. We cannot limit uses or disclosures that are required by law.
To request confidential communication methods. You may ask that we contact you at a certain address or in a certain way. We must agree to your request as long as it is reasonably easy for us to do so.
To find out what disclosures have been made. You may get a list describing when, to whom, why, and what of your Protected Health Information has been disclosed during the past six years. We must respond to your request within sixty days of receiving it. We will only charge you for the list if you request more than one list per year. The list will not include disclosures made to you or for purposes of treatment, payment, health care operations if we do not use electronic health records, our patient directory, national security, law enforcement, and certain health oversight activities.
To receive notice if your records have been breached. Glow Family Dental will notify you if there has been an acquisition, access, use or disclosure of your Protected Health Information in a manner not allowed under the law and which we are required by law to report to you. We will review any suspected breach to determine the appropriate response under the circumstances.
To obtain a paper copy of this Notice. Upon your request, we will give you a paper copy of this Notice.
If you have any questions about these rights, please contact us.
How to Complain about Our Privacy Practices
You may file a complaint with the Secretary of the U.S. Department of Health and Human Services by writing to 200 Independence Avenue SW, Washington, D.C. 20201 or by calling 1-877-696-6775.
We will take no action against you if you make a complaint to either or both of these persons.
We are required by law to maintain the privacy of, and provie individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number.
This signature acknowledges you received the Notice of Privacy Practices and you give consent. You are giving consent to our use and disclosure of your protected health information to carry out treatment, paymen activities, and healthcare operations.