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 this notice carefully. Your privacy is important to us.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your protected health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 3/8/2010 andwill 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 prior tothe changes. Before we make a significant change in our privacy practices, we will change this Notice and provide the new Notice at our practice location.We will also distribute it upon request
You may request a copy of our Notice at any time. For more information about our privacy practices or 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 without authorization for the following purposes:
Questions & Complaints
If you want more information about our privacy practices or have questions or concerns, please contact us. If you feel that:
You may file a complaintusing 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 complaintwith 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. Damon B. Thompson
Address: 250 S. Main St. Ste. 212., Blacksburg, VA 24060
Mutual Commitment Contract
We are committed to a positive patient experience and believe that in order to provide excellent, personalized care for each and every one of our patients, we must first build a foundation of trust between patient and provider. So that we may meet and exceed your expectations, we ask that you commit to fulfilling our expectations for patients in our practice
What You Can Expect of Us, the Provider:
What We Will Expect of You, the Patient:
Regarding Payment for Services
We will gladly process your insurance claims as a courtesy to you, provided you give us detailed and accurate information. It is your responsibility to inform us of any changes to your dental insurance coverage prior to yournext reservation.Your coverage exists as a contract between you and your insurance company, which means that our office does not determine what amount (if any) your insurance company has agreed to pay for treatment. For this reason, we expect our patients to pay their estimated patient portion for treatment at the time of service. If your insurance company fails to pay for any reason, you will be held responsible for the remaining balance on your account. If you do not carry dental benefits, you will be expected to pay your balance in full at the time of serviceunless prior arrangements have been made.You may also be eligible for our Dental Savings Plan.For extensive treatment, we offer payment plans through Care Credit and QuickPay. Please talk to our financial coordinator for further details.
Regarding Changes to Your Reservation
Your reservation time is valuable and has been set aside specifically for you. We acknowledge that circumstances can sometimesprevent patients from being able to keep their reservations, but we ask that you give us enough notice to offer your reserved time to another patient shouldyou need to reschedule. Please notify us at least TWO business days in advance (unless you’re experiencing a true emergency, in which case an exception may be made). Keep in mind that our office is not open on the weekends, which may increase the notice we require. If a habit of last-minute cancellations or missed appointmentspersists over time, you may be required to pay a $50 deposit in order to reserve a spot on our schedule;or we may be unable to continue our patient-provider relationship.
Regarding Privacy Practices
In the course of providing services to you, we create, receive, and store information that identifies you. It is often necessary to use and disclose your health information in order to treat you, obtain payment for our services, and to conduct healthcare operations in our office. The Notice of Privacy Practices that you have received describes these uses and disclosures in detail. Please notify a Patient Coordinator if you have not received a copy of the Notice of Privacy Practices.
Signing this Form Implies Consent to: