PRIMARY INSURANCE

SECONDARY INSURANCE

 I understand the above information and guarantee this form was completed to the best of my knowledge so far. I understand it is my responsibility to inform this office of any changes to the information I have provided.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law.  It also describes your rights to access and control your protected health information.  Protected health information is information about you including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

1. Uses and Disclosure of Protected Health Information Your protected health information maybe used and disclosed by your physician our office staff and other outsides of our office that are involved in your care and treatment for the purpose of providing health care services to you to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

Treatment: We will use and disclose your protect

ted health information to provide coordinate or manage your health care and any related services.  This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home agency that provides care to you.  For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care service.  For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital  

admission.

Healthcare Operation: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice.  These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing and conducting or arranging for other business activities.  For example, we may disclose your protected health information to medical school students that see patients in our office.  In addition, we may use a sign-in sheet at the registration desk where you will be asked ti sign your name and indicate your physician.  We may also call you by name in the waiting room when your physician is ready to see you.  We may use or disclose you protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information, in the following situations without your authorization.  These situation include: as Required by Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, and Organ Donation, Research, Criminal Activity, Military Activities and National Security Workers’ Compensation, Inmates, Required Uses and Disclosures: Under law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164-500. Other Permitted and Required Uses and Disclosures Will Be Made Only with Your Consent, Authorization or Opportunity to Object unless required by law. You may revoke this authorization at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.  

2. Your Rights Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information.  Under federal law, however, you may not inspect or copy the following records: psychotherapy notes, information complied in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information.  This means you may ask us not to use or disclose any part of your protected health information for the purpose of treatment, payments or healthcare operations.  You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices.  Your request must state the specific restrictions requested and to whom you want the restrictions apply.

Your physician is not required to agree to a restriction that you may request.  If a physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted.  You then have the right to use another healthcare professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location.  You have the right to obtain a paper copy of this notice from us upon request, even if you have agreed to accept this notice alternatively, i.e. electronically.

You may have the right to have your physician amend your protected health information.  If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made of any of your protected health information.  We reserve the right to change the terms of this notice and will inform you by mail of any changes.  You then have the right to object or withdraw as provided in this notice.

3. Complaints You may complain to us or to the Secretary of Health and Human Services, if you believe your privacy rights have been violated by us.  You may file a complaint with us by notifying our privacy contact of your complaint.  We will not retaliate against you for filing a complaint.  

This notice was published and becomes effective on/or before April 14, 2003.

We required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information.  If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:

Our ultimate goal is to provide quality care to you, our patients, to educate as many people as possible on the prevention of dental diseases, and to have all our patients in a stable or improving dental condition. In order to achieve this goal, we feel that it is important to keep the line of communication open between our patients and our healthcare staff.

Following are the guidelines concerning our office policy. If you have questions, please do not hesitate to discuss them with us.

APPOINTMENT
Although we will attempt to confirm every upcoming appointment that you have set up with us, we may not always be able to do so. Once an appointment is made, you will be responsible for remembering it. Any appointment cancelled less than 24 hours in advance will be subject to a $35 cancellation fee (specialist cancellation fee is $50)  When we call to confirm your appointment but cannot reach you directly, we will leave messages regarding the time and date of the appointment. Please do call us back to let us know the status of your coming.

FINANCIAL & INSURANCE POLICY
Payment is required as services are rendered. If you have dental insurance, you will be asked to pay your estimated co-payment at the time of treatment. The co-payments that we collect from you during your visits are only estimates given to us from your insurance carrier. They are not meant to be the final figures. You are ultimately responsible for any remaining balance after your insurance has paid its portion.

We will accept any of the following forms of payments: Cash, Checks, Visa, Master Card or Discover. 

In addition to the above, we require that you read, understand and agree to the following terms:

I understand that my insurance is an agreement between my insurance carrier and me. I also understand that I am responsible for the balance of my dental account regardless of insurance.

I understand that I may incur a 1.5% monthly finance charge if my balance ages beyond 60 days.

I assign dental benefit payments to be paid directly to Compass Dental Arts from my insurance carrier. I also authorize Compass Dental Arts to contact my insurance carrier on my behalf regarding the payments for my services.

I give permission for my dentist and his/her clinical team to take any necessary diagnostic x-rays, photos, or study models to properly enable complete diagnosis and treatment.

• You have the right to accept or reject dental treatment recommended by your dentist. This form is intended to provide you with an overview of potential risks and complications. 
• If you fail to follow the advice of your dentist or reject recommended dental treatment , you may increase the chances of a poor outcome. 
•  It is very important that you provide your dentist with an updated and  accurate medical history before treatment. It is equally important that you follow your dentist’s advice and recommendations regarding medication, pre and post treatment instructions, referrals to other dentists or specialists, and return for scheduled follow up appointments. 
• Prior to consenting to treatment, you should carefully consider the anticipated benefits, commonly known risks and complications of the recommended procedures, alternative treatments or the option of no treatment. 
• Please read the items below. 
• Always be certain your dentist has addressed all of your concerns to your satisfaction before commencing treatment. Consider them as partners in helping you achieve your oral health. 

During your course of treatment the following care may be provided to you:

EXAMINATIONS AND X-RAYS Radiographs are required to complete your examination, diagnosis and treatment plan. With radiographs, a more complete diagnosis  can be made when the dental provider can detect problems between the teeth including tooth pulp (nerve health), cavities, tooth fractures, periodontal (gum) disease, etc . A waiver needs to be signed for denied radiographs by patients. Common risks for radiographs are exposure to low dose x-ray radiation. Consequences of not performing treatment result in incomplete diagnosis and undetected problems that may lead to tooth loss, infection or worsening of dental conditions undetected.  A periodic examination will be provided by the dentist at all routine cleanings to evaluate your teeth for decay, gum disease, oral cancer and overall health. The dentist will read and diagnose any x-rays taken. In the state of California a dental hygienist, assistant, and front desk personnel CANNOT diagnose a patient.  

DENTAL PROPHYLAXIS (CLEANING) A routine dental prophylaxis involves the removal of plaque and calculus above the gum line and will not address gum infections below the gum line called periodontal or gum disease . Some bleeding and/or sensitivity after a cleaning can occur, however, should it persist and if it is severe in nature the office should be contacted.  

PERIODONTAL TREATMENT Periodontal  or gum disease is an infection causing gum inflammation and/or bone loss that can lead to tooth loss. At times when a routine cleaning is scheduled,  periodontal disease can be diagnosed in all or certain areas of your mouth. If you present with an infection during your routine cleaning appointment it may be necessary for more extensive treatment to be performed. The dental provider will stop the routine cleaning and explain to you alternative treatment plans including nonsurgical cleaning  (deep cleanings/scaling) below the gum line, placement of an antibiotic below the gum line or a gross debridement (two part cleaning). Oftentimes it will require local anaesthesia (please see overview below)  Further treatment such as gum surgery and/or extractions may still be needed if periodontal disease continues. Some bleeding and sensitivity after deep cleaning or scaling under the gum line can occur, however, should it persist and if it is severe in nature the office should be contacted.. Untreated periodontal disease may have a future adverse effect on the long term success of dental restoration work, longevity of the teeth and bone volume. 

LOCAL ANESTHESIA Anesthetizing agents (medications) are injected into a small area with the intent of numbing the area to receive dental treatment. They also can be injected near a nerve to act as a nerve block causing numbness to a larger area of the mouth beyond just the site of injection.  It may affect your body such as dizziness, nausea, vomiting, increase or decrease in heart rate, or allergic reactions, which may require medical management or hospitalizations. Restriction in mouth opening called trismus, at the site of injection requiring physical therapy. In rare cases, prolonged numbness sometimes causes injury from biting or chewing on areas such as lip, cheek, or tongue. Injury to nerves can result in pain, numbness, tingling, or other sensory disturbances to the chin, lip, cheek, gums, or tongue. This may persist for weeks, months, years, or very rarely permanent. In another rare occurrence, small needles may break off and be lodged requiring surgical removal and/or hospitalization .Potential benefits: Pain is lessened or eliminated during  dental treatment.

RESTORATIONS (FILLINGS) A more extensive restoration than originally diagnosed may be required due to additional decay or unsupported tooth structure that can only be found during preparation of the tooth. If you are receiving temporary fillings, you will need to follow up with your provider for a permanent filling or permanent crown. Sensitivity can be a common aftereffect of a newly placed filling which can last a few days or a few months. This may include (a) hot/cold food & beverage sensitivity, (b) sensitivity when chewing, (c) sensitivity when brushing, and (d) mild to moderate toothache. In rare cases tissue damage from restorative treatment is permanent and the restored tooth will continue to get worse. With some restorations, it may lead to root canal, crown or both. Without a restoration, the increased chance of tooth loss and pain can occur. Occasionally after receiving a filling it may feel high and you may need to return to the office to have the bite adjusted.  

SEALANTS Potential benefits of sealants: Prevention of decay on the biting surfaces on the back teeth (molars/premolars). Risks include but are not limited to the following: Replacement every few years, which is commonly needed but may or may not be covered by dental insurance. Breakage of sealants, which is common with certain habits such as chewing ice or other hard foods. Early loss of sealants, which can be caused by bruxism (tooth grinding). Damage to adjacent teeth and/or tissues.

CROWNS, BRIDGES and VENEERS It is not always possible to match the color of natural teeth exactly with artificial teeth. A temporary crown will typically be made after the initial preparation appointment. Temporary crowns/veneers may come off and you should be careful chewing on them until the permanent crowns are delivered. If a temporary crown/veneer should fall off call the office immediately to make arrangements for a new temporary. The final opportunity to make changes on crowns, bridges or veneers (including shape, fit, size, placement and color) will be done BEFORE  permanent cementation.  In rare occurrences, a root canal may still be needed after crowns, bridges and veneers IF the tooth becomes chronically sensitive (which cannot always be predicted or anticipated). After a crown, bridge or veneer is permanently cemented sometimes your bite may feel high and you may need to return to have the bite adjusted or fixed. Modification of daily cleaning procedures or additional hygiene appointments may be required and if so will be explained to you by your provider.

TEMPOROMANDIBULAR JOINT DYSFUNCTION (TMD) Symptoms of popping, clicking, locking and pain can intensify or develop in the joint of the lower jaw (near the ear) subsequent to routine dental treatment when the mouth is held in the open position. However, symptoms of TMD associated with dental treatment are usually temporary in nature and well tolerated by most patients. If need for treatment should arise, you will be referred to a specialist.

Changes in Treatment Plan 

I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during the examination. The most common being root canal therapy following routine restorative procedures. Permission is given to the dentist to make any/all changes and additions as necessary in the best interest of my oral health. 

Allergies/Medication

 I have informed the dentist of any known allergies I may have. I understand that antibiotics, analgesics and other medications can cause allergic reactions causing redness and swelling of tissues; pain, itching, vomiting and/or anaphylactic shock (severe allergic reaction). They may cause drowsiness, lack of awareness and coordination which can be increased by the use of alcohol or other drugs. I understand and fully agree not to operate any vehicle or hazardous device for at least 12 hours or until fully recovered from the effects of the anesthetic or medication that may have been given to me in the office for my care. I understand that failure to take medications prescribed to me as directed may offer risks of continued or aggravated infection, pain or a negative result on the outcome of my treatment. 

OTHER RARE INCIDENCES: Damage to adjacent/opposing  teeth and tissues  can occur during any dental procedures. Accidental swallowing of aspiration of a foreign body can also occur during any dental procedures 

 I have the right to ask additional questions or concerns and review this form before any treatment begins.  By signing below, I have read each paragraph above and understand the anticipated benefits and commonly known risks and complications of general dental procedures.

To ensure that the public is aware of the most current research information regarding the use of material for dental restorations, the Dental Board of California has prepared a Dental Materials Fact Sheet, which has been distributed, to all dental practitioners in the state. This fact sheet defines the most common dental restorative materials, their uses, and the characteristics of each. As our patient you may at some time have restorative treatment recommended with one or more of these materials. The doctors will suggest Procedure, and thus materials, which are deemed to best, fit your needs. We have also provided an informed consent for general dental care that we would like you to understand. We encourage you to review the information container in these fact sheets carefully and discuss any questions or concerns you may have with the staff before undertaking and restorative procedures.

As required by chapter 801, Statutes of 1992, the Dental Board of California has prepared this fact sheet to summarize information on
the most frequently used restorative dental materials. Information on this fact sheet is intended to encourage discussion between the patient and dentist regarding the selection of dental materials best suited for the patient’s dental needs. It is not intended to be a complete guide to dental materials science.

The most frequently used materials in restorative dentistry are amalgam, composite resin, glass ionomer cement, resin‐ionomercement, porcelain (ceramic), porcelain (fused‐to‐metal), gold alloys (noble), and nickel or cobalt‐chrome (base‐metal) alloys.

Each material has its own advantages and disadvantages, benefits and risks. These and other relevant factors are compared in the attached matrix titled
"Comparisons of Restorative Dental Materials." "A Glossary of Terms" is also attached to assist the reader in understanding the terms used.The statements made are supported by relevant, credible dental research published mainly between 1993 ‐ 2001.

In some cases, where contemporary research is sparse, we have indicated our best perceptions based upon information that predates 1993.
The reader should be aware that the outcome of dental treatment or durability of a restoration is not solely a function of the material
from which the restoration was made.

The durability of any restoration is influenced by the dentist's technique when placing the restoration, the ancillary materials used in
the procedure, and the patient's cooperation during the procedure. Following the restoration of the teeth, the longevity of the restoration will
be strongly influenced by the patient's compliance with dental hygiene and home care, their diet, and chewing habits.

Both the public and the dental profession are concerned about the safety of the dental treatment and any potential health risks that might
be associated with the materials used to restore the teeth.

All materials commonly used (and listed in this fact sheet) have been shown –
through laboratory and clinical research, as well as through extensive clinical use – to be safe and effective for the general population. The
presence of these materials in the teeth does not cause adverse health problems for the majority of the population. There exists a diversity
of various scientific opinions regarding the safety of mercury dental amalgams. The research literature and peer-reviewed scientific journals
suggests that otherwise healthy women, children, and diabetics are not at increased risk for exposure to mercury from dental amalgams.

Although there are various opinions with regard to mercury risk in pregnancy, diabetes, and children, these opinions are not scientifically conclusive and therefore the dentists may want to discuss these opinions with their patients. There is no research evidence that suggests pregnant women, diabetics and children are at increased health risk from dental amalgams fillings in their mouths.

A recent study reported in the JADA factors in a reduced tolerance (1/50th of the WHO safe limit) for exposure in calculating the amount of mercury that might be taken in from dental fillings. This level falls below the established safe limits for exposure to a low concentration of mercury or any other released component from a dental restorative material. Thus, while these sub‐populations may be perceived to be at increased health risk from exposure to dental restorative materials, the scientific evidence does not support that claim. However, there are individuals who may be susceptible to sensitivity, allergic or adverse reactions to selected materials. As with all dental materials, the risks and benefits should be discussed with the patient, especially with those in susceptible populations.

There are differences between dental materials and the individual elements or components that compose these materials. For example, dental amalgam filling material is composed mainly of mercury (43‐54%) and varying percentages of silver, tin, and copper (46‐57%). It should be noted that elemental mercury is listed on the Proposition 65 list of known toxins and carcinogens.

Like all materials in our environment, each of these elements by themselves is toxic at some level of concentration if they are taken into the body. When they
are mixed together, they react chemically to form a crystalline metal alloy. Small amounts of free mercury may be released from amalgam fillings over time and can be detected in bodily fluids and expired air. The important question is whether any free mercury is present in sufficient levels to pose a health risk. Toxicity of any substance is related to dose, and doses of mercury or any other element that may be released from dental amalgam fillings fall far below the established safe levels as stated in the 1999 US Health and Human ServiceToxicological Profile for Mercury Update.

All dental restorative materials (as well as all materials that we come in contact within our daily life) have the potential to elicit allergic reactions to hypersensitive individuals.1 These must be assessed on a case‐by‐case basis, and susceptible individuals should avoid contact with allergenic materials. Documented reports of allergenic reactions to dental amalgams exist (usually manifested by transient skin rashes in individuals who have come into contact with the material), but they are atypical. Documented reports of toxicity to dental amalgam exist, but they are rare. There have been anecdotal reports of toxicity to dental amalgam and as with all dental material risks and benefits
of dental amalgam should be discussed with the patient, especially with those in susceptible populations.

Composite resins are the preferred alternative to amalgam in many cases. They have a long history of biocompatibility and safety. Composite resins are composed of a variety of complex inorganic and organic compounds, any of which might provoke an allergic response in susceptible individuals. Reports of such sensitivity are atypical. However, there are individuals who may be susceptible to sensitivity, allergic or adverse reactions to composite resin restorations. The risks and benefits of all dental materials should be discussed with the patient, especially with those in susceptible populations.

Other dental materials that have elicited significant concern among dentists are nickel‐chromium‐beryllium alloys used predominantly for crowns and bridges. Approximately 10% of the female population are alleged to be allergic to nickel.2 The incidence of an allergic response to dental restorations made from nickel alloys is surprisingly rare. However, when a patient has a positive history of confirmed nickel allergy, or when such hypersensitivity to dental restorations is suspected, alternative metal alloys may be used.

Discussion with the patient of the risks and benefits of these materials is indicated.

Glossary of Terms
General description – Brief statement of the composition and behavior of the dental material
Principal uses – The types of dental restorations that are made from this material.
Resistance to further decay – The general ability of the material to prevent decay around it.
Longevity/durability – The probable average length of time before the material will have to be replaced. (This will depend upon many
factors unrelated to the material such as biting habits of the patient, their diet, the strength of their bite, oral hygiene, etc.)
Conservation of tooth structure – A general measure of how much tooth needs to be removed in order to place and retain the material.
Surface wear/fracture resistance – A general measure of how well the material holds up over time under the forces of biting, grinding,
clenching, etc.
Marginal integrity (leakage) – An indication of the ability of the material to seal the interface between the restoration in the tooth, thereby
helping to prevent sensitivity and new decay.
Resistance to occlusal stress – The ability of the material to survive heavy biting forces over time.
Biocompatibility – The effect, if any, of the material on the general overall health of the patient.
Allergic or adverse reactions – Possible systemic or localized reactions of the skin, gums and other tissues to the material.
Toxicity – An indication of the ability to of the material to interfere with normal physiologic processes beyond the mouth.
Susceptibility to sensitivity – An indication of the probability that the restored teeth may be sensitive to stimuli (heat, cold, sweet,
pressure) after the material is placed in them.
Esthetics – An indication of the degree to which the material resembles natural teeth.
Frequency of repair or replacement – An indication of the expected longevity of the restoration made from this material.
Relative cost – A qualitative indication of what one would pay for a restoration made from this material compared to all the rest.
Number of visits required – How many times a patient would usually have to go to the dentist’s office in order to get a restoration made
from this material.
Dental amalgam – Filling material which is composed mainly of mercury (43‐54%) and varying percentages of silver, tin, and copper (46‐57%).

References: 

1 – Dental Amalgam: A scientific review and recommended a lick help service strategy for research, education and regulation, Dept. of Health and Human Services,
Public Health Service, January 1993.
2 – Merck Index 1983. Tenth Edition, M Narsha Windhol z, (ed)

I acknowledge that I have received the Dental Materials Fact Sheet date October 2001 developed by the Dental Board of California. I understand that this fact sheet has been provided to me in an effort to ensure I am fully informed of the variety of materials available for dental restorations. I understand that I should review this information to make a fully informed decision regarding dental restorative treatment. I also understand that if I have any questions or concerns regarding this information that is my right to discuss these before beginning treatment.

This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID-19 virus.

A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID-19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any
such conditions with us.

It is also important that you disclose to this office any indication of having been exposed to COVID-19 virus.

Due to current COVID-19 policies, you will be asked these exact questions again at every of dental visit  with a temperature scan. 

I fully understand and acknowledge the above information, risks, and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a
compromised immune system.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.