Patient Contact Information

Dental Insurance Information

As dental care providers, we want to emphasize that our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges and payments are your responsibility from the date that services are rendered. We encourage you to read and understand your particular dental policy. By signing below, you authorize the Itani Dental, Inc. to submit charges to your credit card on file to cover balances due 60 days or more.

Patient Health History

4. Women, please answer the following additional questions:
5. Do you have or have you ever had any of the following:

I understand that the information gathered on this medical history form is intended to help inform the Itani Dental Inc. staff of any pre-existing medical conditions so that the best course of treatment can be determined. I understand that failure to disclose this information could affect my own safety. I affirm that the medical information indicated here is accurate and complete.

Dental History

Dental Anxiety Scale

Please answer the following questions by circling the appropriate response.


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 by applicable federal and state law to maintain the privacy of your health information. We are also 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 April 14, 2003, 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 perm itted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all 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 by 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: We 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 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 professional judgment disclosing only health information that is directly relevant 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 to do so by law.

Abuse or Neglect: We may disclose your 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 information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

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 for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your 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 copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must 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 reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $0.00 for each page, $25 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. 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 Accounting: You have the right to receive a list of instance in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. 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 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 to agree to these additional restrictions, but 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 information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory 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 certain 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.


QUESTIONS AND COMPLAINTS

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

If you are concerned that we may have violated your privacy rights, or 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 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. 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.

Samer Itani, DDS

(415) 685-0011

(415)685-0011

mail@itanidental.com

450 Sutter St. Suite 2318, San Francisco, CA 94108

Itani Dental, Inc.


ACKNOWLEDGEMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES


*You May Refuse to Sign This Acknowledgment*

I, , have received a copy of this office’s Notice of Privacy Practices.

Please Print Name
Date

Itani Dental, Inc.


CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION


SECTION A: PATIENT GIVING CONSENT

SECTION B: TO THE PATIENT – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:

Samer Itani, DDS

(415) 685-0011

(415)685-0010

mail@itanidental.com

450 Sutter Street, Suite 2318, San Francisco, CA94108

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

SIGNATURE

I, , have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment payment activities and health care operations.

If this Consent is signed by a personal representative on behalf of the patient, complete the following:

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.

Include completed Consent in the patient’s chart.
REVOCATION OF CONSENT

revoke my Consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations.

I understand that revocation of my Consent will not affect any action you took in reliance on my Consent before you received this written Notice of Revocation. I also understand that you may decline to treat or to continue to treat me after I have revoked my Consent.

© American Dental Association
All Rights Reserved
Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires prior
written approval of the American Dental Association. This form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).

450 Sutter Street, Suite 2318 * San Francisco, CA 94108
(415) 685-0011

Financial and Insurance Policy

Welcome to the Itani Dental! It is our pleasure to have you as our patient. Our commitment is to provide you with the best possible dental care and to keep you informed of treatment recommendations and financial obligations. The following is our office payment policy:

Payment for Services
Payment is due at the time services are rendered, as the Itani Dental, Inc. is a fee for service practice. For certain types of treatment, such as procedures involving sedation or anesthesia, payment may be in advance. We accept cash, Visa, MasterCard, American Express, money orders, and personal checks.

If You Have Insurance
If you have dental insurance, we will be glad to help you receive reimbursement for your allowable benefits. Please keep in mind that your insurance plan is a contract between you, your employer, and the insurance company. The contract is in no way a binding obligation between the Dental Insurance Company and the Itani Dental.
  • Payment is due in full at the time services are rendered.
  • As a courtesy to you, our patient, we will submit a claim to your insurance carrier on your behalf for your reimbursement. Please present your valid insurance card and information at the front desk.
  • Your insurance carrier will review your claim and make a determination of your payment. They may apply your fees to a deductible, require a co-pay, and/or deny coverage/payment. Some services may not be covered by your plan, or your insurance carrier may pay only a portion of the charges. We cannot know these amounts in advance; therefore, payment is your responsibility.
  • Our office does not guarantee that you will receive reimbursement from your insurance company.
  • Please contact your insurance company for answers to specific questions regarding your coverage, their payment policies and reimbursement procedures. Also, please call your insurance company to expedite claims if a claim has not been paid within 30 days.

Other Fees
Returned check fee:
There is a $40.00 fee if your check is returned to our office unpaid by your financial institution.
Outstanding balances:
Outstanding balances over 60 days are subject to collections fees and an interest rate charge of 18% APR.

As dental care providers, we want to emphasize that our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges and payments are your responsibility from the date that services are rendered. We encourage you to read and understand your particular dental policy. By signing below, you authorize the Itani Dental, Inc. to submit charges to your credit card on file to cover balances due 60 days or more.

We hope that by presenting our policies to you, we will avoid any misunderstandings, and therefore, have more time to dedicate to your dental care. If you have any questions regarding the above information, please do not hesitate to ask – we are here to help!


I certify that I have read, understood, and received a copy of the above Financial/Insurance Policy.
I understand my financial responsibility for dental treatment.

450 Sutter Street, Suite 2318 * San Francisco, CA 94108
(415) 685-0011

Cancellation and Missed Appointment Policy

Welcome to the Dental, and thank you for choosing us to treat your dental needs. It is our goal to provide you with the best care possible. When you become a patient of this practice, we commit to your treatment plan and deliver healthy beautiful smiles in a medically safe- and service-oriented setting. To that end, the dentists of The Dental, Inc. limit their selection of patients to those who are most motivated to begin a sequence of treatment appointments that will end up producing an elegant and predictable result. Because of the specialized nature of our practice and our commitment to excellence, we ask every patient to adhere to our cancellation policy.

We place a high value on our patients, and our front office staff will always try to accommodate your emergencies. However, failure to notify our office of a cancellation means that we cannot offer that time to other patients. For this reason, we do enforce a fee for late cancellations and missed appointments.

The number of days for notice of cancellation and the late cancellation fee amount is dependant upon the type of appointment scheduled and the amount of time allotted for the appointment. Unforeseeable emergencies will be taken into consideration if a cancellation fee is assessed.

General Appointments
A general appointment requires two business days (Monday – Friday) notice for cancellations and rescheduling. These appointments include first-visit new patient examinations, follow-up examinations, consultations, prep and seat appointments for crowns, composites, or other restorations. The late cancellation fee for a general appointment is $100.00 per hour for each hour allotted for the appointment. Hygiene Appointments

Hygiene Appointments
A hygiene appointment requires two business days (Monday – Friday) notice for cancellations and rescheduling. These teeth cleaning appointments include prophies, periodontal maintenance and scaling/root planning procedures. The late cancellation fee for prophy or periodontal maintenance appointment is $85. The late cancellation fee for scaling/root planning procedure appointment is $180.00 per hour.

I.V. Sedation and General Anesthesia Appointments
Appointments under sedation require five business days (Monday – Friday) for cancellations and rescheduling once the surgery treatment date is scheduled. These appointments include I.V. sedation, and hospital cases. When you originally committed to this appointment, we allotted a considerable amount of time for your case. Therefore, the appointment can only be cancelled in the event of a medical emergency by the patient’s personal physician, speaking on the phone with Dr. Itani, or by the anesthesiologist. The late cancellation fees for these appointments will be assessed at one-third (33%) of the amount of the treatment plan estimate.

We do respect your time and commitment to your dental health. However, due to the nature of our practice, we acknowledge that we occasionally run behind schedule. We apologize, in advance, for these inconveniences, and ask for your understanding that dental emergencies occasionally create delays in our schedule. Please let us know if you have any questions about this policy. We appreciate your understanding and collaboration.


I certify that I have read, understood, and received a copy of the above Cancellation/Missed Appointment
Policy. I understand my financial responsibility for dental treatment.