Notice of Privacy Practices (Dental)

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU l\IAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY AND SIGN BELOW.

The Health Insurance Portability & Accountability Act of 1996 ("HIPAA") is a federal program that requires all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used "HIPAA" provides penalties for covered entities that misuse personal health information.

As required by "HIPAA", we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use" and disclose your health information.

We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operations.

• Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would Include teeth cleaning services.

Special circumstances would require us to release your personal information. Examples would be public health risks, lawsuits & similar proceedings, law enforcement, deceased patients, organ & tissue donation, research, serious threats to health or safety, military, national security, inmates, & workers' compensation.

• Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.

• Healthcare operations include the business aspects of running our practice, such as conducting quality assessments and improvement activities. auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members. other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. lf we do agree to a restriction, we must abide by it unless you agree in writing to remove it.

• The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
• The right to inspect and copy your protected health information.
• The right to amend your protected health information.
• The right to receive an accounting of disclosures of protected health information.

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

This notice is effective as of this day, this month, and this year we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

I ACKNOWLEDGE THE RECEIPT OF THE NOTICE OF PRIVACY PRACTICES

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.

You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with our office, or with the Department of Health & Human Services. Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing i complaint For more information about HIPAA or to file a complaint:

The U.S. Department of Health & Human Services Office of Civil Rights 200 Independence Avenue, S.W." Washington D.C. 20201 or call (202) 619--0257 or Toll-Free: 1-877-696-6775

OFFICE POLICIES FOR INSURANCE, FINANCIAL ARRAGEMENTS, AND MISSED APPOINTMENT POLICY

Dental Insurance

We accept most insurance plans, but we are not an in-network provider with any plans. Always check with your insurance company about your benefits before receiving treatment. As a courtesy to our paiients with insm·ance, we will file your insurance claim as long as you are able to provide us with current dental information as well as a copy of your insurance card. We will NOT be able to f°Ile your insurance without this information. Afte your initial visit, we ask that you pay your deductible and I or estimated co-payment as services are rendered. Please remember that the contract is between you and your insurance company, and your total balance in our office is always your responsibility. We make every effort to give you an accurate estimate of what your portion of our fees will be based on information provided to us; however, we have no way to guarantee the actual terms of your insurance policy. Ifthere is a balance aiter your insurance company has paid, you will be responsible for that amount. Disputes regarding reimbursement or the amount of the reimbursement are between you and" "your insurance carrier. Without your insurance information, payment must be made in full at the time of your appointment.

Financial Agreement

We attempt to keep our fees at a fair level that reflects the quality of care provided in our office, therefore, prompt payment will enable us to keep our fees lower for everyone. For procedures that take multiple appointments to complete, payment may be split up over the number of appointments required. We accept cash, checks (returned check fee $25.00) Visa, MasterCard, American Express, and Discover. We also offer financing through Care Credit, a convenient no-interest, or low-interest financing payment plan. Please ask at the front desk if interested, and we will review payment options to accommodate your financial needs.

In cases of divorce or separation, the party responsible for the account is the parent authorizing the treatment of the child.

Missed Appointment Policy

We ask that you notify us as early as possible if you are unable to keep your appointment. When you schedule your appointment, you have reserved this time in our schedule. If you cancel or change your appointment, we require that you contact our office at 847-516-1616, AT LEAST 24 HOURS IN ADVANCE. This allows our other patients to fill your time slot for the treatment they require. If you do not keep your appointment and have not called to reschedule or cancel at least 24 hours in advance of your appointment, you will be charged our Missed Appointment FEE OF $25.00.

I have read, understand and agree to adhere to the policies outlined above.

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.