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972.646.7774

opdsmiles@gmail.com
www.opdsmiles.com

ORTHO ADULT PATIENT FORM

WELCOME TO OUR PRACTICE
PATIENT INFORMATION
FIRST
Middle
Last
STREET
APT
CITY
STATE
ZIP
INSURANCE INFORMATION
SECONDARY INSURANCE
MEDICAL HISTORY
DENTAL HISTORY

SIGNATURE OF RESPONSIBLE PARTY

SIGNATURE OF DENTIST

Notice of Privacy Practices

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 protected health information, and to notify affected individuals following a 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 August 15, 2018 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, and to make new Notice provisions effective 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 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.

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 substance abuse records, and mental health records may be entitled to special confidentiality protections under applicable state or federal law. We will abide by these special protections as they pertain to applicable cases involving these types of records.

Treatment. We may use and disclose 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 information to obtain reimbursement for the treatment and services you receive from us or another entity involved with your care. Payment activities include 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 healthcare operations. For example, healthcare operations include quality assessment and improvement activities, conducting training programs, and licensing 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 institution 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 oversight 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 other 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 request.

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 out 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 on 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 producible. 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 an accounting of disclosures of your health information, you must submit your request in writing to the Privacy Official. If you request 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 case where the disclosure is to a health plan for purposes 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 Communication. You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. You must make your request in writing. Your request must specify the alternative means or locations, and provide satisfactory explanation of how payments with 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 explain 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 (e-mail).

Questions and Complaints
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 complaint to the U.S. Department of Health and Human Services, Office of Civil Rights; 200 Independence Avenue, SW; Washington DC 20201; (202) 619-0257; Toll Free: 1-877-696-6775.

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.

If you want more information about our privacy practices or have questions or concerns, please contact us:

Choy Ortho-Pedo PLLC
DBA: OPD Smiles Orthodontics &
Pediatric Dentistry
501 Sounth Angel Parkway Suite 400
Lucas, TX 75002
(972) 646 - 7774
www.opdsmiles.com

NOTICE OF PRIVACY PRACTICES
PARENT/GUARDIAN DISCLOSURE FORM

This form is required by the Health Insurance Portability and Accountability Act of 1996 in compliance with the privacy regulation effective for this office on August 15, 2018, only if our office wishes to use or disclose your protected health information for any other purpose not clearly spelled out in our office Privacy Policy Notice.

To use or disclose your protected health information in such cases, our office must receive prior written authorization from you. Our office will condition treatment, payment, enrollment or eligibility for benefits on whether you sign this authorization.

The purpose for which our office is requesting your authorization is to diagnose and complete treatment. The information to be disclosed would include your protected health information (PHI). The information may be disclosed to, but not limited to, laboratories, hospitals, insurance companies, medical and dental referrals, and other health care professionals. This form also authorizes the use of photography as a diagnostic tool.

By agreeing to this authorization, you understand that the potential for information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by the privacy regulation of HIPAA. You also understand that you are entitled to receive a copy of this authorization form.


ACKNOWLEDGEMENT NOTICE OF
PRIVACY PRACTICES
**You May Refuse to Sign This Acknowledgement**

Parent / Guardian Name

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of the protected health information, (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.


I wish to be contacted in the following manner: (check all that apply)

(Please note that we cannot ensue end user security of your email, text messages, or e-faxes)

Parent / Guardian Signature:

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FINANCIAL POLICY ACKNOWLEDGEMENT

Our practices are proud to be a part of a team whose primary mission is to deliver the finest and most comprehensive dental care services today. In order to assist you with your health care investment, we are providing the following payment information and options.

PAYMENT
Payment is due at the time services are rendered. We accept cash, personal checks with the current date, all major credit cards, and debit cards. We also offer some 0% interest plans through Care Credit, or we can set up an in-office payment plan that will automatically bill a credit card on a set interval. We will be happy to help you with this. Financing your treatment will allow you to begin your treatment immediately and spread the cost over a period of time.

All returned checks are subject to $35.00 returned check fee.

Accounts over 90 days past due will be referred out for collection and the patient is responsible for any fees associated with that.

INSURANCE
As a courtesy to our patients, we are happy to file your claims to your insurance carrier. We will make every reasonable effort to collect covered amounts from your insurance company. Deductibles, co-payments and non-covered amounts (including fees above your insurance company’s usual and customary fee schedule) are due at the time services are rendered. All estimates quotes are based upon information provided to us by your insurance company and are estimates only and not a guarantee of payment. The patient is ultimately responsible for all charges incurred. Insurance companies are required by law to pay or deny claims within 45 days. After 60 days, any unpaid claims will be resubmitted by our office, and we ask that you follow-up as well. After 90 days, we ask that you pay in full and have your insurance company reimburse you. We will be happy to provide any information or documentation you may require. Our first and only priority is our patients and the quality of care. The negotiation of benefits is between you, your employer and insurance company.

TREATMENT PLANS
Should you or your child require dental treatment, these needs will be discussed with you by one of our staff members. In most cases, an additional appointment(s) will be needed to complete the treatment. The payment amount provided to you on the treatment plan is an estimate only, and you will be asked to pay the difference between what your insurance company actually paid and the fees incurred at the time of service.

CANCELLATIONS
It is the philosophy of our office to provide optimal patient care. All patients are seen by appointment only and are scheduled with your individual needs in mind. This allows us to focus our efforts on caring and treating our patients to the best of our abilities. We do require 24 hours notice for cancellations and reschedules. This is necessary to allow us adequate time to notify patients who are on a waiting list for the first available appointment. If 2 broken/missed appointments occur or 2 cancellations without at least 24 hours notice, we reserve the right NOT to schedule any subsequent appointments. We also reserve the right to charge a cancellation fee of $25 per patient.

I have read the above and understand and agree to these terms. I hereby authorize the release of any dental information necessary to process insurance claims. I authorize the payment of benefits to be directly to OPD Smiles Orthodontics and Pediatric Dentistry.


Patient/Parent/Guardian Signature:

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Web, Social Media, & Photo Release Form

I hereby authorize you to use or disclose the specific information described below, only for the purposes and parties also described below.

Description of the specific information to be used or disclosed:

• Photographs and/or video of Dental Treatments

Person/entity requesting the information and authorized to make the requested use or disclosure:

• OPD Smiles Orthodontics and Pediatric Dentistry

This information is being requested for the following purpose(s): Patient & Employee Education, Promotion, Marketing, Print or Ads.

This authorization shall remain in effect from the date signed below until 01/01/2050 (expiration date or event)

I understand that:

• I may inspect or copy the protected health information to be used or disclosed

• I may revoke this authorization in writing by contacting your office at the address above, attention Privacy Officer.

• Information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer be protected by HIPAA.

• I may refuse to sign this authorization and that you will not condition treatment or payment on my providing this authorization (except to the extent that the authorization is for research-related treatment, in which case you may refuse to provide that research-related treatment).

photographs posted within our dental practice and/or on our website, social media accounts, video, or slide shows presentations, print ads and all other marketing or advertising efforts that promote our dental practice.


Patient/Guardian/Parent Signature (Over 18years old / patient signature)