NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
We are required by law to maintain the privacy of your health information. We are also required to provide you with this notice of our legal duties and our privacy
practices with respect to your health information. Other than the uses and disclosures we described below, we will not sell or provide any of your health information
to any outside marketing organization.
We must abide by the terms of this notice while it is in effect, but we reserve the right to change the policy terms of our privacy notices. If we make a change, it will
apply for all your health information in our files, and we will notify you in writing if/when you come in for treatment
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
Here are some examples of how we might use or disclose you health care information:
- We may have to disclose your health information to another health care provider, or a hospital, etc., if it is necessary to refer you to them for the diagnosis
assessment, or treatment of your health condition.
- We may have to disclose your examination and treatment records and your billing records to another party (i.e. your insurance company) if there are
potentially responsible for the payment of services.
- We may need to use any information in your file for quality control purposes or any other administrative purposes to run our practice
- We may need to use your name, address, phone number, and your clinical records to contact you to provide appointment reminders, information about
treatment alternatives, or other health related information that may be of interest to you. If you are not at home to receive an appointment reminder, a
message will be left on your answering machine and/or mailed
You have the right to refuse to give us authorization to contact you regarding your case at this office. If you do not give us authorizations, it will not affect the
treatment we provide to you or the methods we use to obtain reimbursement for your care including billing you by mail or collection proceedings. You may inspect or
copy the information that we use to contact you regarding your care at any time.
YOUR RIGHT TO LIMIT USES OR DISCLOSURES
You have the right to request that we do not disclose your health information to specific individuals, companies, or organizations. Any restriction should be requested
in writing. We are not required to honor those requests. However, if we agree with your restrictions, the restriction is binding on us.
PERMITTED USES AND DISCLOSURES WITHOUT YOUR CONSENT OR AUTHORIZATION
Under federal law, we are also permitted or required to use or disclose your health information without your consent or authorization in the following circumstances:
- We are providing health care services to you based on the orders (referral) of another health care provider.
- We provide health care services to you in an emergency and we are unable to obtain you consent after attempting to do so.
- If there are substantial barriers to communicate with you but in our professional judgment we believe that you intend for us to provide care.
REVOKING YOUR AUTHORIZATION
You may revoke your authorization to us at any time in writing. There are two circumstances under which we will not be able to honor your revocation request:
If we have already released your health information before we receive your request to revoke your authorization.
If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right your health information if they decide
to contest any of your claims
We will attempt to accommodate any reasonable written request how/where (i.e. mailing address, contact number) you would like to receive information about your health or the services that we provide.
AMENDING YOUR HEALTH INFORMATION
You have the right to request that we amend your health information for seven years from the date the record was created or as long as the information remains in
our files. We require a written request to amend your records that includes a valid reason to support the change. We have the right to refuse your request.
INSPECTING/COPYING YOUR HEALTH INFORMATION
You have the right to inspect the health information contained in your files while in our office and/or have a copy made for you. The health information is available for seven years from the date that the record was created or as long as the information remains in our files. Your request must be made in writing to inspect he records and/or have them copied. There will be a charge of $.50 per page copied. Copies can be made of your x-rays for a charge of $10.00 for each film. The original film is the property of this office because we are required by law to keep it in our records. Original films can only be release on referral to another physician at our discretion.
We cannot control the actions of others to who we have released your information for treatment. Information that we use or disclose may be subject to redisclosure by those individuals/facilities and may no longer be protected by federal privacy rules
ACCOUNTING OF DISCLOSURES OF YOUR RECORDS
You have the right to request an accounting of any disclosures made of your health information for six years prior to the date of your request. The request must be in writing. The accounting will exclude the following disclosures:
- Required for your treatment, to obtain payment for services, to run our practice, and/or made to you.
- Necessary to maintain a directory of the individuals in our facility or to individuals involved with your care
- For national security, intelligence purposes, or law enforcement officers.
- That were made prior to of effective date of the HIPAA privacy law (April 14, 2003)
We will provide the first accounting within a 12-month period without charge, but any additional requests will be charged a fee. When you make your request we will tell you the amount of the fee and you will have the opportunity to withdraw or modify your request.
The full fee of your dental treatment is due the day the services are rendered unless prior arrangements are made. If you have dental insurance, we will handle the submission of all claims for you to receive your benefits.
Note: Your insurance is a contract between you, your employer, and the insurance carrier. We are not a part of that contract. We do not base your diagnosed treatment on your insurance coverage; instead basing it on your clinical needs and desires.
Fees quoted to you are estimated. There occasionally may be a clinical condition warranting a different treatment and/or fee. Once this is determined, the change will be discussed with you prior to continuing treatment. Quoted fees are honored up to 90 days.
A $45 non-sufficient fund fee will be charged for all returned checks.
Any overdue balances that are unpaid will result in a late fee of $25.00/month.
Broken appointments and appointments cancelled less than 24 hours advance notice will be subject to a fee of $35.00
By signing, I acknowledge that I was given the opportunity to read and ask questions.