DENTAL INSURANCE:

MEDICAL INSURANCE:




PAYMENT POLICY




  • 1) Cash, Check or Money Order (5% discount given for treatment over $500.00)
  • 2) Visa, MasterCard, Discover and American Express Cards
  • 3) Care Credit Card

MISSED APPOINTMENT POLICY


AUTHORIZATION AND RELEASE OF INFORMATION


MEDICAL HISTORY FORM




PERSONAL DENTAL NEEDS SURVEY



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Release of Records




PEDIATRIC TM/AIRWAY-SLEEP SCREENING Form


ADULT TM/AIRWAY-SLEEP SCREENING Form




Office and payment Policy

PAYMENT POLICY




  • 1) Cash, Check or Money Order (5% discount given for treatment over $500.00)
  • 2) Visa, MasterCard, Discover and American Express Cards
  • 3) Care Credit Card

MISSED APPOINTMENT POLICY

AUTHORIZATION AND RELEASE OF INFORMATION

GENERAL DENTAL INFORMED CONSENT FORM

DENTAL RESTORATIVE MATERIALS: THE CHOICES









NOTICE OF PRIVACY PRACTICES





  • when a state or federal law mandates that certain health information be reported for a specific purpose;
  • for public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices
  • disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;
  • uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws;
  • disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
  • disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else;
  • disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial, or to organizations that handle organ or tissue donations;
  • uses or disclosures for health related research;
  • uses and disclosures to prevent a serious threat to health or safety;
  • uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials to lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;
  • disclosures of de-identified information;
  • disclosures relating to worker’s compensation programs;
  • disclosures of a “limited data set” for research, public health, or health care operations;
  • incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
  • disclosures to “business associates” who perform health care operations for us and who commit to respect the privacy of your health information. Unless you object, we will also share relevant information about your care with your family or friends who are helping you with your dental care.



  • ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. We do not have to agree to this, but if we agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to the contact person at the address, fax or Email shown at the beginning of this Notice.
  • Ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using Email to your personal Email address. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to the office contact person at the address, fax or Email shown at the beginning of this Notice.
  • Ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us (or sixty days if the information is stored off-site). You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to the office contact person at the address, fax or Email shown at the beginning of this Notice.
  • Ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30 day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to the office contact person at the address, fax or Email shown at the beginning of this Notice.
  • Get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want). By law, the list will not include; disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization, incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law, we can have one 30 day extension of time if we notify you of the extension in writing. If you want a list, send a written request to the office contact person at the address, fax or Email shown at the beginning of this Notice.
  • Get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you got one electronically or in paper form already. If you want additional paper copies, send a written request to the office contact person at the address, fax or Email shown at the beginning of this Notice.