I understand that I am financially responsible for any treatment performed, whether or not I have Dental Insurance. I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment that my insurance company does not cover.
PATIENTS ARE EXPECTED TO MAKE PAYMENT WHEN SERVICES ARE RENDERED
THE INVESTMENT NECESSARY TO COMPLETE DENTAL TREATMENT IS AN ESTIMATE BASED ON INFORMATION FROM OUR EXAMINATION. SHOULD ADDITIONAL PROBLEMS ARISE AS TREATMENT PROGRESSES, THIS ESTIMATE MAY BE REVISED.
As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.
If you answer yes to any of the 4 items above, please stop and return this form to the receptionist
Note: Both doctor and patient is encouraged to discuss any and all relevant patient health issues prior to treatment.
I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his or her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form
To Our Patients:
Welcome to our office! We are delighted that you have selected us for your dental health care services. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of our mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.
Payment Policy: Payment is due at the time of service. We accept MasterCard, Visa, Discover, American Express, Care Credit, Checks, Debit Card, Care Credit, Lending Club, Wells Fargo and Cash.
For any payments made with your debit or credit card, a 3.95% fee will be added to your receipt.
All overdue accounts will be assessed an annual 18% finance charge and you will be responsible for any collection service fees. There will be a $35.00 fee assessed for any checks returned unpaid.
Insurance Policy: Co-payments are due at the time of service. (ie: Your estimated share of costs that your insurance company will not cover. This amount will be due at the time of service).
We are pleased to assist you in processing your dental insurance. However, dental insurance policies are a contract between the patient and the insurance company. Therefore, we request that you keep your account current with us and personally consult your insurance company for services not covered.
Coupon Offerings: Payments and coupons must be presented at time of check-in.
Cancellation Policy: Please be aware that confirmation calls are a courtesy service only. Patients are responsible for their appointments. If you miss an appointment and fail to notify us at least 24 hours in advance, a missed appointment fee of between $30.00 and $100.00 will be billed to your account.
Thank you again for selecting us as your Dental Health Care Provider.
¹Subject to credit approval²However, if we do not receive payment from your insurance carrier within 60 days, you will be responsible for payment of your treatment fees and collection of your benefits directly from your insurance carrier.
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
We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protect health information, and to notify affected individuals following breach of unsecured protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 24th 2015, and will remain 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, and to make new Notice provisions affective for all protected health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new Notice upon requested.
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.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
We may use and disclose your health information for different purposes, including treatment, payment and health care operations, for each of these categories; we have provided a description and an example. Some information such as HIV-related information, genetic information, alcohol and/or substances abuse records, and metal health records may be entitled to special confidentiality protections under applicable state on federal law. We will abide by these special protections as they pertain to applicable cases involving types of records.
Treatment. We may use and disclosure your health information for your treatment. For example, we may disclose your health information to a specialist providing treatment to you.
Payment. We may use and disclose your health insurance to obtain reimbursement for the treatment and services you receive from us or another involved with your care. Payment activities including billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your dental health plan containing certain health information.
Healthcare Operations. We may use and disclose your health information in connection with our health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities.
Individuals Involved in Your Care or Payment for Your Care. We may disclose your health information to your family or friends or any other individual identified by you when they are involved in your care or in the payment for your care. Additionally, we may disclose information about you to a patient representative. If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information.
Disaster Relief. We may use or disclose your health information to assist in disaster relief efforts.
Required by Law. We may use or disclose your health information when we are required to do so by law.
Public Health Activities. We may disclose your health information for public health activities, including disclosures to:
· Prevent or control disease, injury or disability;
· Report child abuse or neglect;
· Report reactions to medications or problems with products or devices;
· Notify a person of a recall, repair, or replacement of products or devices;
· Notify a person who may have been exposed to a disease or condition; or
· Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence
National Security. We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional instructions or law enforcement official having lawful custody the protected health information of an inmate or patient.
Secretary of HHS. We will disclose your health information to the Secretary of the U.S. Department of Health and Human Services when required to investigate or determine compliance with HIPAA.
Worker’s Compensation. We may disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.
Law Enforcement. We may disclose your PHI for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order.
Health Oversight Activities. We may disclose your PHI to an oversight agency for activities authorized by law. These over sight activities include audits, investigations, inspections, and credentialing as necessary for licensure and for the government to monitor the health care system, government programs and compliance with civil rights laws.
Judicial and Administrative Proceedings. If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request. Or another lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about, the request or to obtain an order protecting the information requested.
Research. We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information.
Coroners, Medical Examiners, and Funeral Directors. We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to enable them to carry their duties.
Fundraising. We may contact you to provide you with information about our sponsored activities, including fundraising programs, as permitted by applicable law if you do not wish to receive such information from us you may opt out of receiving the communications.
OTHER USES AND DISCLOSURES OF PHI
Your authorization is required, with a few exceptions for disclosure of psychotherapy notes, use or disclosure of PHI for marketing and for the sale of PHI. We will also obtain your written authorization before using or disclosing your PHI for purposes other than those provided for in this Notice (or as otherwise permitted or required by law). You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization.
YOUR HEALTH INFORMATION RIGHTS
Access. You have the right to look at or get copies of your health information, with limited exceptions. You must make the request in writing. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice. If you request information that we maintain or paper we may provide photocopies. If you request information that we maintain electronically, you have the right to an electronic copy. We will use the form and format you request if readily protectable. We will charge you a reasonable cost based fee for the cost of supplies and labor of copying, and for postage if you want copies mailed to you. Contact us using the information listed at the end of this Notice for an explanation of our fee structure.
If you are denied a request for access, you have the right to have the denial reviewed in accordance with the requirements of applicable law.
Disclosure Accounting. With the exception of certain disclosures you have the right to receive an accounting of disclosures of your health information in accordance with applicable laws and regulations. To request this accounting of disclosure of your health information, you must submit your request in writing to the Privacy Official. If you requested this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to the additional requests.
Right to Request a Restriction. You have the right to request additional restrictions on our use or disclosure of your PHI by submitting a written request to the Privacy Official. Your written request must include (1) what information you want to limit (2) whether you want to limit our use, disclosure or both, and (3) to whom you want the limits to apply. We are not required to agree to your request except in the casa where disclosure is to a health plan for purpose of carrying out payment or health care operations, and the information pertains solely to a health care item or service for which you or a person on your behalf (other than the health plan), has paid our practice in full.
Alternative Communications. You have the right to request that we communicate with you about your health information by alternative means or at alternative location. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. We will accommodate all reasonable requests. However, if we are unable to contact you using the ways or locations you have
requested we may contact you using the information we have.
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 certain circumstances. If we agree to your request, we will amend your record(s) and notify you of such. If we deny your request for an amendment we will provide you with a written explanation of why we denied it and explained your rights.
Right to Notification of a Breach. You will receive notifications of breaches of your unsecured protected health information as required by law.
Electronic Notice. You may receive a paper copy of this Notice upon request, even if you have agreed to receive this Notice electronically on our Web site or by electronic mail (email).
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or has questions or concerns, please contact us.
If you are concerned that we may have violated your privacy rights, or if you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complain 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.
Telephone: (781) 337-3300
Fax: (781) 337-0308
Address: 47 Washington Street
Weymouth, MA 02188
Email: comfortdental@weymouthsmiles.com
Comfort Dental Weymouth
*You May Refuse to Sign This Acknowledgment*
I have received a copy of this office’s Notice of Privacy Practices.
For office Use Only
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:
GENERAL CONSENT
Please read this form carefully. Should you have any questions, our staff will be happy to help you.
1.) I hereby authorize and direct the dentist and/or dental auxiliaries to perform dental treatment with the use of any necessary or advisable radiographs (x-rays) and/or any other diagnostic aids in order to complete a thorough diagnosis and treatment plan.
2.) I understand x-rays, photographs, models of the mouth, and/or other diagnostic aids used for an accurate diagnosis and treatment planning are the property of the doctors but copies of certain aids are available upon request for a fee.
3.) In general terms, the dental procedure(s) can include but not limited to:
A. Comprehensive oral examination radiographs, cleaning of the teeth, and the application of topical fluoride.
B. Application of resin "sealants" to the grooves of the teeth.
C. Treatment of disease or injured teeth with dental restorations (fillings).
D. Treatment of disease or injured oral tissue secondary to traumatic injuries and/or accidents and/or Infections.
4.) I understand that the doctor is not responsible for previous dental treatment performed in other offices. I understand that, in the course of treatment, this previously existing dentistry may need adjustment and/or replacement. I realize that guarantees of results or absolute satisfaction are not always possible in dental health service.
5.) I certify that I, and/or my dependents have insurance coverage and assign directly to the dentist all insurance benefits for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
6.) I have answered all of the questions about me or my dependent's medical history and present health condition fully and truthfully. I have told the dentist or other office personnel about all medical conditions, including allergies. I also understand if my dependent or I ever have any changes in health status or any changes in medication(s). I will inform the doctor at the next appointment.
I hereby acknowledge that I have read and understand this consent and the meaning of its contents. All questions have been answered in a satisfactory manner and I believe I have sufficient information to give this informed consent. I further understand that this consent shall remain in effect until terminated by me.
@2010, 2013 American Dental Association – All Rights Reserved
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