I consent to be a patient, at the above named office and agree to a radiographic and clinical examination. I also understand and consent to the following:
Bluebonnet Dental is committed to providing all our patients with exceptional care and with giving everything the best dental experience possible. When a patient cancels without giving proper notice, it can prevent another patient from being seen and adequately cared for.
No-Show Appointment Definition:
Rescheduling or cancelling less than 2 hours prior to start time of appointment. Arriving 15 minutes or more after start time of appointment. Not showing up at all to appointment.
Cancelled Appointment Definition:
Patient notifies the office less than 48 hours before a scheduled appointment.
Please call us at 281-501-9372 no later than 1pm two days prior to your scheduled appointment to notify us of any changes. To reschedule a Monday appointment, please give us a call no later than 1pm the previous Thursday. To reschedule a Tuesday appointment, please give us a call no later than 12pm the previous Friday.
A $75 fee will be charged for a no-show appointment.
A $50 fee will be charged for a cancelled appointment.
I hereby authorize Bluebonnet Dental and/or any of their assignees to take photographs, slides, and/videos of my face, jaws, and teeth.
I understand that the photographs, slides, and/or videos will be used as a record of my care, and may be used for educational purposes in lectures, demonstrations, advertisinig (including website publication, newspapers, magazines, phone books, television), and professional publications (dental magazines and journals).
I further understand that if the photographs, slides, and/or videos are used in any publication or as a part of demonstration, my name (First Name Only) or other identifying information could be used unless stated differently below. I do not expect compensation, financial or otherwiese, for the use of these photographs.
Please initial: blanksI do not mind if my first name, face, and teeth are used in any of the above stated situations.Exceptions (Please initial)
blanks I do not wish to have my first name shown, or released.
I do not wish to have my face shown.
blanks I only agree to have my teeth shown without any identifying features.
blanks I do not wish to have my photos used at all.
We are privileged you have chosen Bluebonnet Dental and Brad Barker, DDS, LVIF as your dentist. We are committed to providing you and your family with quality patient care. The following is a statement of our Financial Policy, which you need to understand prior to treatment. If you have any questions, please feel free to ask.
Full patient is due at the time of service. Any outstanding balances are due prior to additional services. We accept cash, checks, and most major credit cards. There will be a $35.00 fee on all returned checks. We reserve the right to charge for appointments cancelled or broken without 24 hours advance notice.
Your insurance policy is a contract between you and your insurance company. We have no control over their decisions and the amount they decide to pay.
However, as a courtesy to you, we will help you process all of your dental insurance claims. Please understand that we will provide an insurance estimate to you; however, it is not a guarantee that your insurance will pay exactly as estimated. Insurance coverage is subject to limitations, exclusions, waiting periods, frequency, age restrictions, deductibles and maximums which are your responsibility. Please contact your insurance company for a detail of your benefits. Your insurance company and your plan benefits ultimately determine the amount paid. We will do all we can to ensure your estimate is as accurate as possible. Your estimated insurance benefit may differ due to a number of reasons, specifically related to your plan.
YOU REMAIN FULLY RESPONSIBLE FOR PAYMENT OF YOUR BILL, REGARDLESS OF WHAT YOUR INSURANCE COMPANY PAYS.
Once payment is received on your claim, we will send you a bill of any remaining balance on your account. At our discretion, any unpaid balance after 90 days will be sent to collections at which the patient is responsible for any fees associated with the collection for the balance.
I have read and understand the above Financial Policy. By signing below, I acknowledge responsibility and agree to the terms above.
As a courtesy to our patients, Bluebonnet Dental keeps a credit/debit card authorization on file for each patient visit and will charge the card for any balance not
paid by your insurance for that visit only. If your visit has a $0 balance, then there will be no further charge or refund.
Please note that the security of your personal information is very important to us. Your credit/debit card data is stored securely and we notify you before any charges are incurred, unless otherwise noted by your specific financial situation.
I have read, understand and agree to the above terms and conditions. I authorize my insurance company to pay my dental benefits directly to my dental office. I understand that responsibility for payment for dental services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered. I authorize Bluebonnet Dental to charge my credit/debit card for any outstanding balances that remain after insurance reimbursements have been applied for authorized medical services received at Bluebonnet Dental. I understand that I will be billed directly by, and agree to pay, Bluebonnet Dental for any outstanding balances should my credit/debit card be declined or canceled. I also agree to reimburse Bluebonnet Dental the fees of any collection agency, which may be to to 40% of the balance owed, along with all costs and expenses, including reasonable attorneys’ fees, if incurred in such collection efforts. If my account is sent to collections, such fees will be assessed by the collection agency on behalf of Bluebonnet Dental. Similarly, I understand that I may be responsible for my balance due to any chargeback, reversal, or dispute as a result of my credit card company’s or bank’s refusal to remit payment to Bluebonnet Dental.
Use and Disclosure of Health Information Consent Form
Please read the following statement carefully.
By signing this form, you will consent to our use and disclosure of your protected health information, including x-rays, photographs, and videos to carry out treatment, payment activities, clinical review and training, 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 practices, clinical review and training, and healthcare operations of the uses and disclosures we may make of your protected healthcare operations, and of other important matters about your protected health information. A copy of this notice is available upon request. 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 at any time by contacting our office.
Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation of this Consent. Your revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation. We may decline to treat you or continue treating you if you revoke this Consent.
By signing this consent form, you 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, clinical review and training, and healthcare operations.
NOTICE OF PRIVACY PRACTICE
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 required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you 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 the Notice while it is in effect. The Notice takes effect January 1, 2018, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of thies Notice at any time, provided such changes are permitted 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 retain, 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 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 providers, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. 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 disclose health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or location) 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 incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgement and disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgement and our experience with common practice making reasonable inference 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 communication with your written authorization.
Required by Law: We may use or disclose your health information when we are required 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, domestic violence, or the possible victim or other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or the health and safety of others.
National Security: We may disclose to military authorities the health information of armed forces Personnel under circumcircle stances. We may disclose to authorized Federal officials health information required for lawful intelligence, counterintelligence, and other National Security concerns. We may disclose to Correctional Institution or law enforcement officials having lawful custody of protected health information of an inmate or patient under circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters)
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 practically 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 requested copies, we have the right to charge you $0.10 for each page, $30 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 instances in which we or our business associates disclose your health information for purposes other than treatment, payment, Healthcare operations, and certain other activities for the last 6 years, but not before January 1st, 2018. 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 may Place additional restrictions on our use of your disclosure of health information. We are not required to agree to these additional instructions 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 our location and provide a satisfactory explanation of 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 made in writing and it must explain why the information should be amended. We may deny your request under circumstances.
Electronic Notice: If you received this Notice on our website or buy email, you are entitled to receive this Notice in written form.
Questions and Complaints: 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 a 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 use using the contact information listed at the end of this Notice. you may also 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.
If you want more information about your privacy practices or have questions or concerns, please contact our office.
2600 S. Gessner Rd. 414
Houston, TX. 77063