Financial Policy, Patient Medical History and Privacy Policy Notice

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Financial Policy

Our Dental Practice is proud to be a team whose primary mission is to deliver the finest and most comprehensive dental services available today. We are concerned about your dental care and want to ensure that it is performed in the most responsible manner. In order to assist you with the investment in your dental health we have outlined our payment policy.

Our policy is that payment is due in full for your liability. (The amount that is not covered by your dental insurance carrier.) For your convenience we accept cash, check, money orders, credit cards, and Care Credit.

We understand the value of insurance benefits that you may receive. Upon receipt of your insurance information, our dental team will gladly verify your dental benefits and inform you of your coverage. We accept direct payment from your insurance carrier, however, we require any known deductible or copayments at the time of service. Our team will file a claim on your behalf at no charge.

Signing this form allows Best Dental Group to secure financing through an outside credit source in the event that your liability is not met within 45 days after services are rendered and after insurance benefits have been received.

An appointment is reserved time specifically for you so we can offer you the highest quality treatment possible. In consideration of all our patients who need to be treated in a timely manner, we require a 48-hour cancelation notice or a $50-$100 will be applied to your bill. (This does not apply to patients with medical emergencies or severe illness). A seven-day notice is required to cancel or change all surgical appointments in order to avoid our cancellation fee.

If your account is assigned to an attorney for collection and/or suit, the prevailing party shall be entitled to reasonable attorney fees and costs of collections including billing and postage. To the extent necessary to determine liability for payment and to obtain reimbursement,. I authorize the disclosure of my record. I understand that I am financially responsible for all charges whether or not paid by my insurance company. I hereby authorize the said assignee to release all information necessary to secure payments. Our office will implement an automatic $10.00 monthly billing fee for all accounts that are 60 days past due.

I fully understand and agree to the above policy. I was given the opportunity to ask any questions.

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.

PATIENT MEDICAL HISTORY

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Conditions

Allergies

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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.

( If under 18, Parent or Guardian Signature Required )

Privacy Policy Notice

SECTION A: The Patient

SECTION B: Acknowledgement of Receipt of Privacy Practices Notice

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.

If a personal representative signs this authorization on behalf of te individual, complete the following:

Acknowledgement of Recipient of Privacy Practices Notice

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 it carefully. The privacy of your health information is important to us.

Our Legal Duty

Federal and state law requires us to maintain the privacy of your health information. That law also requires us to give you this notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices we describe in this notice while it is in effect. This notice takes effect April 14, 2003, and will 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 applicable law permits the changes. 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 before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and make the new notice available upon request.

You may request a copy of our notice at any time. For more information about our privacy practices, or for 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 for treatment, payment, and health care operations. For example:

Treatment: We may use your health information for treatment or disclose it to a dentist, physician or other health care provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you. We may also disclose your health information to another health care provider or entity that is subject to the federal Privacy Rules for its payment activities.

Health Care Operations: We may use and disclose your health information for our health care operations. Health care operations include quality assessment and improvement activities, reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities. We may disclose your health information to another health care provider or organization that is subject to the federal privacy rules and that has a relationship with you to support some of their health care operations. We may disclose your information to help these organizations conduct quality assessment and improvement activities, review the competence or qualifications of health care professionals or detect or prevent health care fraud and abuse.

On Your Authorization: You may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any uses or disclosures permitted by your authorization while it was 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.

To Your Family and Friends: We may disclose your health information to a family member, friend, or other people to the extent necessary to help with your health care or with payment for your health care. Before we disclose your health information to these people, we will provide you with an opportunity to object to our use or disclosure. If you are not present, or in the event of your incapacity or an emergency, we will disclose your medical information based on our professional judgment of whether the disclosure would be in your best interest. We may use our professional judgment and our experience with common practice 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. We may use or disclose information about you to notify or assist in notifying a person involved in your care, of your location and general condition.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters.)

Disaster Relief: We may use or disclose your health information to a public or private entity authorized by law or by its charter to assist in disaster relief efforts.

Public Benefit: We may use or disclose your medical information as authorized by law for the following purposes deemed to be in the public interest or benefit:

  • as required by law;
  • for public health activities, including disease and vital statistic reporting, child abuse reporting, FDA oversight, and to employers regarding work-related illness or injury;
  • to report adult abuse, neglect, or domestic violence;
  • to health oversight agencies;
  • in response to court and administrative orders and other lawful processes;
  • to law enforcement officials pursuant to subpoenas and other lawful processes, concerning crime victims, suspicious deaths, crimes on our premises, reporting crimes in emergencies, and for purposes of identifying or location a suspect or other person;
  • to coroners, medical examiners, and funeral directors;
  • to organ procurement organizations;
  • to avert a serious threat to health or safety;
  • in connection with certain research activities;
  • to the military and to federal officials for lawful intelligence, counterintelligence, and national security activities;
  • to correctional institutions regarding inmates; and
  • as authorized by state worker's compensation laws.

Patient Rights

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You may request access by sending us a letter to the address at the end of this notice. If you request copies, we will charge you a reasonable cost-based fee that may include labor, copying costs, and postage. If you prefer, we may--but are not required to--prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this notice for more information about fees.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information over the last 6 years (but not before April 14, 2003). That list will not include disclosures for treatment, payment, health care operations, as authorized by you and for certain other activities. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Contact us using the information listed at the end of this notice for more information about fees.

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 to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Any agreement we may make to a request for additional restrictions must be in writing signed by a person authorized to make such an agreement on our behalf. Your request is not binding unless our agreement is in writing.

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. You must make your request in writing. You must specify in your request the alternative means or location, and provide satisfactory explanation how you will handle payment under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why we should amend the information. We may deny your request under certain circumstances.

Questions and Complaints

If you want more information about our privacy practices or have questions or concerns, please contact us using the information listed at the end of this notice.
If you believe that:

  • we may have violated your privacy rights,
  • we made a decision about access to your health information incorrectly,
  • our response to a request you made to amend or restrict the use or disclosure of your health information was incorrect, or
  • we should communicate with you by alternative means or at alternative locations,

you may contact us using the information listed below. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with 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.

Provider Contact Office: Best Dental Group
Telephone: (630) 830-4930
Address: 106 W. Bartlett Avenue, Bartlett, IL 60103

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