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THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice describes the privacy practice of Concord Dental. “We" and “our" means the Dental Practice. “You and “your" means our patient.
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and controls your protected health information. “Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services.
1. Uses and Disclosures of Protected Health Information
Uses and Disclosures of Protected Health InformationYour protected health information may be used and disclosed by your dentist, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing dental care services to you, paying your dental care bills, support the operation of the dental practice, and any other use required by law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your dental care and any related services. This includes the coordination or management of your dental care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the dentist has the necessary information to diagnose or treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for your dental care services. For example, obtaining approval for a dental care may require that your relevant protected health information be disclosed to the dental plan to obtain approval for the necessary services.
Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your dental practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of dental students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to dental school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your dentist. We may also call you by name in the waiting room when your dentist is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers' Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.
Other Permitted and Required Uses and Disclosures Will Be Made Only with Your Consent, Authorization, or Opportunity to Object unless required by law.
You may revoke this authorization, at any time, in writing, except to the extent that your dentist or the dental practice has taken an action in reliance on the use or disclosure indicated in the authorization.
Your RightsFollowing is a statement of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.
You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
Your dentist is not required to agree to a restriction that you may request. If your dentist believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted You then have the right to use another Healthcare Professional.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us. upon request, even if you have agreed to accept this notice alternatively i.e. electronically.
You may have the right to have your dentist amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made. if any. of your protected health information.
We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.
ComplaintsYou may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint.
We will not retaliate against you for filing a complaint.
How to Contact Us/Our Privacy Official
If you have any questions or would like further information about this Notice, you can either write to or call the Privacy Official for our Dental Practice:
Dental Practice Name: Concord Dental Group
Privacy Official for Dental Practice: Heather Spiros
Dental Practice mailing address: 3802 S. Lindbergh Blvd. Suite 108 Sunset Hills, MO 63127
Dental Practice email address: firstname.lastname@example.org
Dental Practice phone number: (314)842-2038
This notice was published and becomes effective on/or before April 14.2003.
We are required by law to maintain the privacy of, and provide 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.
I give Concord Dental Group my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for healthcare operations like quality reviews.
I have been informed that I may review the practice’s Notice of Privacy Practices (for a more complete description of uses and disclosures) before signing this consent.
I understand that this practice has the right to change its privacy practices and that I may obtain any revised notices at the practice
I understand that I have the right to request a restriction on how my protected health information is used. However, I also understand that the practice is not required to agree to the request. If tire practice agrees to my requested restriction, they must follow the restriction(s).
I also understand that I may revoke this consent at any time, by making this request in writing, except for the Information already used or disclosed.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
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SECONDARY INSURANCE INFORMATION
Although dental personnel primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
Thank you for choosing Concord Dental Group for your dental needs. We are committed to your treatment being successful. Please Understand That Payment or your bill is considered part of your treatment. The following is a statement of our financial policy, which we require you to read and sign prior to any treatment.Full payment is due at the time of service. We accept cash, checks, Visa, MasterCard, Discover, and American Express. If financing is needed, Care Credit offers 6,12,18,24 month interest-free finance options to those who qualify.There is a $40.00 handling fee for any returned check. Attorney and collection fees incurred in an effort to enforce payment will be the responsibility of the patient/guarantor. Failure to sign this contract does not negate the responsible party from financial responsibility for any services that have been rendered, as submission of treatment implies consent as outlined in the agreement. We reserve the right to charge interest in the amount of 1.5% as provided by state law.FOR PATIENTS WITH INSURANCE: As a service to our patients, we will accept "assignment of benefits" and will bill your insurance carrier, provided all necessary insurance information is provided to our office at the time of service. Every effort will be made to closely estimate your co-payments and deductibles that are due at the time of service. Account balances are your responsibility whether the insurance company pays or not. It is our office policy to collect all co-insurance deductibles and non-covered amounts at the time of service. Please understand that insurance coverage and benefits are contracted between you and your insurance company. If an insurance carrier has not paid within 60 days of service (regardless of reason), any unpaid professional fees are due and payable in full, from you. Once your career has paid the claim, any difference will be due upon receipt of our statement. Again, all account balances, regardless of insurance status, are due within 90 days of service.ADULT PATIENTS: Adult patients are responsible for full payment at the time of service.MINOR PATIENTS: The adult accompanying a minor and the parents( or guardians of the minor) are responsible for full payment. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized to an approved credit plan, Visa/MasterCard/Discover/American Express, or payment by cash or check at time of service has been verified.
USUAL AND CUSTOMARY RATE: Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary in our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates. The fees we charge for dental services are the same for every patient, insured or not. A given insurance policy, however, is based on a fixed fee schedule - "usual and customary" - that may have nothing to do with the real world. Dentistry has changed very quickly, but insurance fee schedules have not. After all, insurance companies are profitable businesses, not dental benefactors.MISSED OR CANCELLATION OF APPOINTMENTS: Our goal is to provide high-quality care at a low cost to our patients and in fairness to other patients and the doctor, we require at least 24 hours notice when canceling an appointment. You will be responsible for a $25.00 fee for missed appointments without 24-hour notification. The practice reserves the right to dismiss patients with excessive canceled appointments.I have read and understood the above financial policy for payment of professional fees. I understand and agree that I AM RESPONSIBLE FOR ALL FEES FOR SERVICES PROVIDED TO ME as outlined above.
I grant full permission to Concord Dental Group to use either my photograph or my child's photograph to showcase before and after smiles on the Concord Dental Group website, Facebook page, and waiting room display book. I understand that no names will be attached to any photographs.
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General Dentist St Louis, MO - Concord Dental Group
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