PRIMARY INSURANCE
Please provide a copy of your insurance card at first appointment as well as secondary if applicable
DENTAL HISTORY
CHECK IF YOU HAVE ANY OF THE FOLLOWING PROBLEMS
To the best of my knowledge, the above information is correct and complete. If there is ever a change in the above health information, I agree to inform the dentist or staff at the next appointment without fail. (If the parent or guardian is signing for a minor, please print your name in addition to signing.)
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.
PATIENTS WITH DENTAL INSURANCE COVERAGE
Please understand that your insurance policy is a contract between you and your insurance company. We are not a party to that contract. We will be glad to help you obtain the appropriate benefits from your insurance carrier as a courtesy to you. However, you are responsible for the payments of the account. Regarding insurance plans where we are a participation provider, all co-pays and deductibles are due prior to treatment. If your insurance company has not paid the claim within 45 days, the balance will be automatically transferred to you. In some cases, insurance carrier may pay for alternative benefits other than the treatment performed. In this case, you are responsible to pay for the difference. Even if you have dual coverage (which is possible when you and your spouse both have insurance) there may still be a portion that is your responsibility. All procedures involving lab work will require 50% down, and the remaining 50% balance will be due as treatment progresses. The balance must be paid before final delivery/insertion. If you are having extensive treatment over a period of time, we request payments during the course of treatment. Our financial coordinator will assist you in arranging a payment schedule.
PATIENTS WITHOUT DENTAL INSURANCE COVERAGE
Patients without dental insurance coverage are required to pay for service as rendered. We accept Cash, Check, Mastercard, Visa, or Debit/ATM cards. We also arrange pre-payments and no-interest financing through Care Credit (www.carecredit.com)
OFFICE POLICY CONCERNING SCHEDULING APPOINTMENTS
When you make an appointment, we reserve that time for you. We understand that extreme or unavoidable emergencies or circumstances do arise which may require you to cancel your appointment. We reserve the right to charge for any appointment(s) broken without a 24 hour notice. The charge for missed appointments will be $50.00
BILLING POLICY
Check returned unpaid from bank is subject to a $35 service fee.
Accounts delinquent more than 90 days from the billing are subject to a 1.5% per month (18% annually) finance charge. If your account is sent to our collection agency you will be responsible for the 35% collection fee of balance.
We welcome you to our office and want to provide you with the best dental care possible. If you have any questions regarding our financial guidelines and your treatment, please don’t hesitate to ask. We are here to help you any way we can!
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.
Protecting your confidential health information is important to us! We take the Federal HIPAA – Health Insurance Portability and Accountability Act laws seriously in order to protect the privacy of your health information
HOW YOUR HEALTH INFORMATION MAY BE USED
We will use and communicate your health information only for the purposes of providing your treatment, obtaining payment, and conducting health care operations. Your health information will not be used for other purposes unless we have asked for and been voluntarily given your written permission.
To Provide Treatment
We will use your health information within our office to provide you with the best dental care possible. This may include administrative and clinical office procedures designed to optimize scheduling and coordination of care between hygienist, dental assistant, dentist, and business office staff. In addition, we may share your health information with physicians, referring dentists, clinical and dental laboratories, pharmacies or other health care personnel providing you treatment
To Obtain Payment
We may include your health information with an invoice used to collect payment for treatment you receive in our office. We may do this with insurance forms filed for you in the mail or sent electronically. We will be sure to only work with companies with a similar commitment to the security of your health information.
To Conduct Health Care Operations
Your health information may be used during performance evaluations of our staff. Some of our best teaching opportunities use clinical situations experienced by patients receiving care at our office. As a result, health information may be included in training programs for students, interns, associates, and business and clinical employees. It is also possible that health information will be disclosed during audits by insurance companies or government-appointed agencies as part of their quality assurance and compliance reviews. Your health information may be reviewed during the routine process of certification, licensing, or credentialing activities.
In Patient Reminders
Since regular care is very important to your oral and general health, we will remind you of a scheduled appointment or that it is time for you to contact us and make an appointment. Additionally, we may contact you to follow up on your care and inform you of treatment options or services that may be of interest to you or your family.
These communications are an important part of our philosophy of partnering with our patients to be sure they receive the best preventative and restorative care modern dentistry can provide. They may include postcards, letters, telephone reminders, or email.
Abuse
It is our duty to notify government authorities if we believe a patient is the victim of abuse, neglect or domestic violence. We will make this disclosure only with the patient’s agreement or when we are compelled by our ethical judgment and believe we are required or authorized to do so by law.
Public Health and National Security
We may be required to disclose health information to Federal officials or military authorities when this information is necessary to complete an investigation related to public health or national security. Health information can be important when the government believes that the public safety could benefit. The information could lead to control or prevention of an epidemic or the understanding of new side effects or a drug treatment or medical device.
For Law Enforcement
As permitted or required by State or Federal law, we may disclose your health information to a law enforcement official for certain law enforcement purposes including, under certain limited circumstances, if you are a victim of a crime or in order to report a crime.
Family, Friends, and Caregivers
We may share your health information with those you tell us will be helping you with your home hygiene, treatment, medications, or payment. In the case of an emergency where you are unable to tell us what you want, we will use our very best judgment when sharing your health information only when it will be important to those participating in providing your care.
Authorization to Use or Disclose Health Information
Other than is stated above or where Federal, State or Local law requires us, we will not disclose your health information other than with your written authorization. You may revoke that authorization in writing at any time.
Restrictions
You have the right to request restrictions on certain uses and disclosures of your health information. Our office will make every effort to honor reasonable restriction preferences from our patients.
Confidential Communications
You have the right to request that we only communicate with you in a certain way. You may request that we only communicate your health information privately with no other family members present or through mailed communications that are sealed. We will make every effort to honor your reasonable request for confidential communication.
Inspect and Copy Your Health Information
You have the right to read, review, and copy your health information, including your complete chart, xrays, and billing record. We may need to charge you a reasonable fee for duplication and assembly costs. If you would like a copy of your health information, please let us know.
Amend Your Health Information
You have the right to ask us to update or modify your records if you believe your health information records are incorrect or incomplete. We will be happy to accommodate your request as long as our office maintains this information. Please provide us with your request in writing and describe your reason for the change.
Documentation of Health Information
You have the right to ask us for a description of how and where your health information was used by our office for any reason other than for treatment, payment or health operations. Our documentation procedures will enable us to provide your health information for at least the past 5 years in accordance with subsection 1 and 7 NRS 629.051. Please let us know in writing the time period for which you are interested. We may need to charge you a reasonable fee for duplication and assembly costs.
Request a Paper Copy of this Notice
You have the right to obtain a copy of this Notice of Privacy Practices directly from our office at any time. Stop by or give us a call, and we will mail or email a copy to you.
We are required by law to maintain the privacy of your health information and to provide to you and your representative this Notice of our Privacy Practices. We are required to practice the policies and procedures described in this notice, but we do reserve the right to change the terms of our Notice. If we change our privacy practices we will provide you with a revised Notice.
You have the right to express complaints to us or to the Secretary of Health and Human Services if you believe your privacy rights have been compromised. We encourage you to express any concerns you may have regarding the privacy of your information.
PATIENT ACKNOWLEDGMENT
acknowledge that I have received a Notice of Privacy Practices from Marvel Dental, Ltd.
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