The Following Questions Are Intended For WOMEN Only:
Dear Valued Patient:
In order to keep fees to a minimum and continue to provide the best quality care for our patients, our office financial policy is summarized here.
We ask that patients pay for their treatment at the time of service, as detailed by insurance benefit plans and coverages. We are not responsible for services that are not covered by your dental insurance plan or balances that have not been paid by your insurance. You are responsible for your account and it is our courtesy to assist you with insurance benefit details. Please be certain of your commitment to your treatment prior to initiation of any said dental treatment.
The following is a common insurance copyament protocol utilized by most but not all insurance plans:
Basic Services: Co-Payment of 20-30% is requiredMajor Services: Co-Payment of 50-60% is required
Note: Any insurance plan that pays directly to the patient requires that the patient make payment in full at the time of service, which is stipulated by the insurance company.
Appointments are reserved specicically for you. Kindly give our office a 48-hour notification if you need to cancel or reschedule. Please see the forthcoming cancellation policy and contact policy forms.
We appreciate your understandig of this policy. We look forward to serving you and your family's dental health needs.
Please sign and date below, signifying that you have read and understand our policy.
This Notice describes how your health information may be used and disclosed and how you can get access to this information Please review it carefully as the privacy of your health information is important to us.
Our Legal DutyFederal and state laws require us to maintain the privacy of your health information. We are also required to provide this Notice about our office's privacy practices, our legal duties, and your rights regarding your health information. We are required to follow the practices outlined in this Notice while it's in effect. This Notice takes effect 01-01-2017 and will remain until we replace it. We reserve the right to change our privacy practices and terms at any time. We reserve the right to make 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 significant change in our privacy practices, we will change this Notice and provide new Notices upon request. For more information, please contact us at (310) 278-3666.Uses and Disclosure of Health InformationA. Treatment: We disclose medical information to our employees and others involved in providing the care you need. We may use or disclose your health information to another dentist or other healthcare providers providing treatment that we do not provide. We may share your health information with a pharmacist, or a laboratory that performs tests or fabricates dental prostheses or orthodontic appliances.B. Payment: We may use and disclose your health information to obtain payment for services we provide you, unless you request against when you have paid out of pocket and in full for rendered services. C. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include, but are not limited to, quality assessment, improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certificaton, licensing or credentialing activities. D. Your Authorization: In addition to your health information for treatment, payment, healthcare operations, you may give us written authorization to use your health information to anyone for any purpose. You may revoke this authorization at any time and will not affect any use or disclosures permitted by your authorization while it's 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. E. To Your Family and Friends: You have the right to request restrictions on disclosure to family members, relatives, friends, any person identified by you. F. Unsecured Email: We will not send you unsecured emails pertaining to your health information without your prior authorization. You may revoke this authorization at any time. G. Persons Involved In Care: We may use or disclose your health information to notify or assist in the notification of a family member, personal representative, person responsible for your care, of your location, general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. If you are incapacitated or in emergency circumstances, we will disclose health information based on our professional judgment. We will also use our professional judgment 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. H. Change of Ownership: If this dental practice is sold or merged with another practice or organization, your health records will become the property of the new owner. You may request that copies of your health information be transferred to another dental practice. I. Required By Law: We may use or disclose your health information when we are required to do so by law.J. Public Health: We may, and are sometimes legally obligated to disclose your health information to public health agencies for purposes related to preventing or controlling disease, injury or disability; reporting 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. Upon reporting suspected elder or dependent adult abuse or domestic violence, we will inform you or your personal representative unless we believe the notification would place you at risk of harm or would require informing a personal representative we believe is responsible for the abuse or harm. K. 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 disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. L. Appointment Reminders: We may contact you to provide you with appointment reminders via voicemal, text message, or post mail. We may also leave a message with the person answering the phone if you are not available. We may send emails or text messages to confirm appontments but will not contain any health information. Please see the forthcoming release form for additional information. M. Sign In Sheet and Announcement: We may use and disclose medical information about you by asking that you sign an intake sheet at our front desk or we may announce your name when we are ready to see you.
Patient RightsA. Access: You have the right to look at/get copies of you health information, with limited exceptions. This request must be in writing, you may request a form from us if you prefer. You may request that we provide copies in a format other than photocopies; we will use the format you request unless we cannot. We may charge a fee for expenses such as copies and staff time.B. Disclosure Accounting: You have the right to receive a list of instances in which we disclosed your health information for the last six years. If you request this accounting more than once in a 12-month period, we may assess a fee.C. 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. In the event you pay out of pocket and in full for services rendered, you may request that we not share your health information with your health plan and we must agree to this request.D. Alternative Communication: You may request in writing that we communicate with you about your health information by alternative means that are detailed in your request. E. Breach Notification: In the event your unsecured protected health information is breached, we will notify you as required by law. You may be notified by our business associates.F. Amendment: You have the right to request that we amend your health information. Request must be in writing and must explain why the information should be amended. We may deny your request under certain circumstances. Questions and ConcernsIf you would like more information about our privacy practices or have questions or concerns, please contact: Dr. Nicole Barkhordar, Phone Number (310) 278-3666. Email: email@example.com Address: 9301 Wilshire Blvd, Suite #407 Beverly Hills, CA 90210.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 alternative locations, you may send a written complaint to our office or to the U.S. Department of Health and Human Services, Office of Civil Rights. We will not retaliate against you for filing a complaint.
Acknowledgement of Receipt of Notice of Privacy Practices:I have reviewed the Notice of Privacy Practices of Beverly Hills Specialty Dental Care.
If this Acknowledgement is signed by a personal representative on behalf of the patient, please complete the following:
Our goal is to provide personal dental care in a timely manner. Late cancellations, late reschedules, no shows, and late arrival to appointments disrupts this goal. Therefore, we would like to inform you of our cancellation and late policies. If it is necessary to cancel or reschedule your scheduled appointment, we require that you inform our office at least 48 hours prior to your appointment. You may contact us by telephone at (310) 278-3666, by text at (310) 498-0140, or by email at firstname.lastname@example.org.Failure to provide proper notice will result in a $75 cancellation fee. This fee is not covered by insurance and is your responsibility.
Arrival to your scheduled appointment 15 minutes or longer past the appointment time can result in the forfeit of your appointment time. Late arrival to appointment or no show to appointment may result in a $75 cancellation fee also not covered by insurance.
For these reasons, we require a credit card to be on file for your accont should you incure any charges.
YOU WILL NOT BE CHARGED BY ENTERING YOUR INFORMATION.
You will only be charged if you incur a late/reschedule/cancellation fee.
We have the ability to provide our patients with certain types of information via email and/or text messaging. We strongly believe in protecting the privacy of our patients. When you provide this information to us, it is only used as a way to communicate with you. Texts and e-mails may contain information regarding appointment reminders, scheduling appointments, and insurance information.
In order to protect your privacy, no confidential information will be sent from us via e-mail or text message. We do not share the names, email addresses, and/or telephone numbers of patients with any other persons.
By signing below, I acknowledge that I have read and understand the above statement regarding emails and text messages and agree to receive these correspondence. I hereby give permission to send messages to me via email and/or text messaging as a means of communication.
1. Work which may be done:
2. Drugs and Medications: I understand that antibiotics, analgesics, anesthetics and other medications may cause allergic reactions causing redness or swelling of tissue, pain, itching, vomiting and/or anaphylatic shock. I have advised my dentist of any and all medications I am currently taking, including but not limited to prescription medications, over-the-counter medications, herbal remedies, and alternative medications. I understand that failure to advise of any medications I am taking prior to starting dental work may have unforeseen consequences for me.
3. Changes in treatment plan: I understand that there may be a change to my treatment plan during treatment as conditions may be found while working on the teeth that were not discoverable during initial exam. For example, root canal treatment may be necessary following routine restorative procedures. All changes to treatment plans will be discussed with me.
4. Endodontic Treatment: I realize there is no guarantee that root canal therapy will save my tooth and that complications can occur from treatment. I understand that endodontic files are very fine instruments and stresses from their manufacture can cause them to break in my tooth during treatment. I understand that occasionally additional surgical proceures may be necessary following root canal treatment (apicoectomy), or the root canal may be short or have other complications and may need to be redone. My root might also be perforated during the procedure which may cause me to lose the tooth. I understand that the tooth may be lost in spite of all efforts to save it and that a root canal is not a guarantee the tooth will be saved.
5. Periodontal Treatment: I understand that if I am being treaded for periodontal disease, this means I have a serious condition causing gum and bone inflammation or loss and that it can ultimately lead to the loss of my teeth. Alternative treatment plans have been explained to me, including gum surgery, replacements and/or extractions. I understand that any dental procedure may have a future adverse effect on my periodontal condition.
6. Fillings: To avoid breakage, I understand that care must be taken when chewing on fillings, especially during the first 24 hours. Iunderstand that more extensive filling than originallydiganosed may be required due to additional decay. I understand that increased sensitivity is a common effect of a newly placed filling.
I understand that dentistry cannot properly guarantee results. I acknowledge that no guarantee or assurance has been made to me regarding the dental treatment(s) which I have authoized.