Advanced Family Dentistry Forms

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Treatment & Financial Plan Policy

Our Pay-At-The-Desk policy helps avoid the high costs of billing, thus keeping your visits less costly. Please help us by being prepared to pay at the time of your visit.

  1. All insurance co-payments are due upon delivery of treatment. This includes all deductibles, co-payments, and procedures that are not covered by insurance company.
  2. All payments are due on delivery of treatment. If patient wishes to be billed or requests a financial plan, one can be given. However, no further treatment will be performed unless prior procedures and treatment is paid in full.
  3. For all major work which requires multiple visits, patient must have a down payment at the time of the initial visit.
  4. A finance charge of 1.5% monthly (18.0% APR) will be charged on all balances over 60 days old.

We will accept Visa, MasterCard and Discover.

Your appointments are very important to us. This time is reserved just for YOU. Therefore, patients must advise OUR office of any changes in your appointments within 24 hours. If appointments are cancelled in less than 24 hours and scheduled time cannot be filled there will be a $50.00 no show I cancellation fee. Please schedule appointments that do not conflict with your schedule to avoid any unwanted charges or fees.

I have read and accurately completed the health history form attached.

Jeffrey A. Gee, D.D.S.

Advanced Family Dentistry

329 South Pine Avenue

Morgan, NJ 08879

(732) 721-2424

www.jeffreygeedentist.com

Acknowledgement of receipt of notice of privacy practices

**You May Refuse to Sign This Acknowledgement**

have received a copy of this office's Notice of Privacy Practices.

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

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required 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 that are described in this Notice while it is in effect. This Notice takes effect (MM/DDNR), 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 changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for a" 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 healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: Wee may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, 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 use 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 must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your 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. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly rel evant to the person's involvement in your healthcare. We will also 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. Marketing Health·Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect : We may disclose you r 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 infClrmation to the extent necessary to avert a seriolls threat to YOllr health or safety or the health or safety of others. Nation al Security: We may disclose to military authorities the health information at Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful mtelligence, countenntelligence, and other national security activities. We may disclose to correctional institution ar law enforcement afficial having lawful custody of protected health information of inmate ar patient under certain circumstances.

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

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 capies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You ml/st make a request In writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice We will charge you a reasonaule cost·based fee for expenses such as caples and staff time. You may also request access by sending LIS • letter to the address at the end of this Notice. If you request copies , we will Charge you $0._ for each page, $ ___ per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to YO ll. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will 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 a full explanation of our fee structure.)

Disclosure Ac counting: You have the right to receive a list of instances in which we or our business associates disclosed your hea lth information for purposes, other than treatment, payment, healthcare operations and celtain other activities, for the last 6 years , bllt not before ,Il,pril 14, 2003. If you request this accounting more than once in a 12·month penod, we mall charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You haVE the right to request that we place additional restrictions on our use or disclosure of your health information. We are not req uired to agree to these additional restrictions, bllt if we do, we will abide by our agreement (except In an emergency).

Alternative Communication : You have the right to request that we communicate with you about your health mformation by alternative mean s or to alternative locations. {You must make your request in writing.} Your request must specify the alternative means or location, and provide satisfa ctory explanation how payments will be handled 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 the information should be amended.) We may deny your request under certa in circumstances.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

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