I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist.
I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.
I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.
Payment is due in full at time of treatment, unless prior arrangements have been approved.
I agree to notify the dental practice if within 2 days I become ill with COVID-19 symptoms or test positive for COVID-19. I understand that the dental practice has a legal and ehtical obligation to inform me if a staff person I had close contact with tested positive for COVID-19 within 2 days.
Acepto dar aviso o lo clínica dental si dentro de dos días presento síntomas de COVID-19 o tengo un resultado positivo de COVID-19. Entiendo que la clínico dental tiene la obligación legal y ético de informarme si un miembro del personal con el que tuve contacto ho tenido un resultado positivo de COVID-19 dentro de dos días.
HIPPA Notice of Privacy Practices (See the bottom of this form.)
I have received and have been given the opportunity to review the Notice of Privacy Practices.
Dental Materials Fact Sheet (See the bottom of this form.)
I have received a copy of the Dental Materials Facts Sheet.
Appointment Cancellations Policy
Your appointment time is reserved specifically for you. Other than in an emergency, if you are unable to keep your appointment, please give us 2 business days’ notice. You get plenty of texts, calls and/or emails up to one month before your appointment to allow plenty of time to reschedule. If advance notice is not received, a charge of $50 may apply.
Insurance/Payment PolicyYou are ultimately responsible for the entire cost of your treatment regardless of your insurance coverage. Our office will process insurance claims as a courtesy to you, based on insurance information provided by you. We do everything we can to have an accurate estimate of the patient portion for your treatment. Please note that any estimates given are estimates only and are not guarantee of payment as some restrictions set forth by your insurance camer may apply. Please note that payments for dental services are usually due on the day services are rendered if you don’t have insurance or within 30 days of receipt of a statement from us, unless you have made specific arrangements with our office.
Our office uses email and text to communicate with you regarding appointments and office/patient needs. For your privacy, we do not send out detailed dental/health/financial information. I agree to electronic communication with the dental practice at the email/text below. I am aware that there is some risk that unencrypted emails may be viewed by third parties. I am responsible for keeping the email address or cell number on file current and I reserve the right to terminate electronic communication with the office by calling 650-344-7888.
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.
Office of Ben Yount, DDS
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that health providers keep your medical and dental information private. The HIPAA Privacy Rule states that health providers must also post in a clear and prominent location, and provide patients with, a written Notice of Privacy Practices.
The privacy practices described are currently in effect. We reserve the right to change our privacy practices, and the terms of this Notice, at any time, provided such changes are permitted by law. If changes are made, a new Notice of Privacy Practices will be displayed in our office and provided to patients. You may request a copy of our Notice at any time. Additional information may be obtained from the HIPAA Coordinator listed in our written HIPAA Plan.
USES AND DISCLOSURES OF HEALTH INFORMATION
The following describes how information about you may be used in this dental office:
· Treatment Services: We may use or disclose your health information to all of our staff members, other dentists, your physicians, and or other health care providers taking care of you.
· Payment and Health Care Operations: We may use and disclose your health information to obtain payment for services we provide to you, to participate in quality assurance, disease management, training, licensing, and certification programs. Upon your written request, we will not disclose to your health insurer any services paid by you out of pocket.
· Marketing/Fundraising: We will not use your health information for marketing or fundraising purposes without your written consent. You can opt out of receiving information about our marketing or fundraisers. We will not sell your health information without your explicit authorization.
· Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders such as voicemail messages, email, postcards, or letters.
· Legal Requirements: We may disclose your health information when required to do so by law.
· Abuse or Neglect: If abuse or neglect is reasonably suspected, we may use of disclose your health information to the appropriate governmental authorities.
· National Security: When required, we may disclose military personnel health information to the Armed Forces. Information may be given to authorized federal officials when required for intelligence and national security activities. Health information for inmates in custody of law enforcement may be provided to correctional institutes.
· Family Members, Friends, and Others Involved in Care: At your request, we may disclose your health information to a family member or other person if necessary to assist with your treatment and/or payment for services. Based on our judgment and as per 164.522(a) of HIPAA we may disclose your information to these persons in the event of an emergency situation. We also may make information available so that another person may pick up filled prescriptions, medical supplies, records, or x-rays for you. Your information may be disclosed to assist in notifying a family member, caregiver, or personal representative of your location, condition, or death.
· Business Associates: Some services in our organization are provided through contacts with business associates. Examples include practice management software representatives, accountants, answering service personnel, etc. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we have asked them to do and bill you or your third-party payer for services rendered. All of our business associates are required to safeguard your information and to follow HIPAA Privacy Rules.
· Workers’ Compensation: We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.
· Research: We may use or disclose medical information to researchers when an institution’s review board or special privacy board has reviewed the proposed study and established protocols to ensure the privacy of the health information used in their research and determined that the researcher does not need to obtain your authorization prior to using your medical information for research purposes.
· Public Health Activities: We may disclose medical information for public health activities, to include the following: to prevent or control disease, injury, or disability; to report reactions with medications or problems with products, to notify people of recalls of products they may be using; to notify a person who may have been exposed to a disease or who may be at risk for contracting or spreading a disease of condition; to notify the proper government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence (when required by law).
· Other Authorizations: 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.
· Breach Notification: We will notify you any time your PHI may have been compromised through unauthorized acquisition, access, use or disclosure.
· 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.
We will charge you a reasonable cost-based fee for expenses such as copies. If you request X-Rays, there will be a fee for any copies of films. You are not entitled to originals, only copies. Postage will be added if copies are to be mailed. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Details of all fees are available from the HIPAA Coordinator.
· Accounting of Disclosures: You have the right to receive a list of instances 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. 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 will keep your information confidential from your health plans if you pay in cash, at your request. In some instances, we may not be required 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 must explain the reason for the amendment.) We may deny your request under certain circumstances.
QUESTIONS AND COMPLAINTS
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 HHS.
HIPAA Coordinator: Ben Yount, DDS
Telephone: 650-344-7888 Fax: 650-348-1330
Address: 720 N. El Camino Real, San Mateo, CA 94401
California Dental Materials Fact Sheet
This California Dental Materials Fact Sheet is provided by the CDA and is required in California to be made available to all new patients and to existing patients once before treatment. Please cross reference the statements made in the CA fact sheet about the World Health Organizations possition on dental mercury with the World Health Organization’s current publication.
What About the Safety of Filling Materials?Patient health and the safety of dental treatments are the primary goals of California’s dental professionals and the Dental Board of California. The purpose of this fact sheet is to provide you with information concerning the risks and benefits of all the dental materials used in the restoration (filling) of teeth.The Dental Board of California is required by law* to make this dental materials fact sheet available to every licensed dentist in the state of California. Your dentist, in turn, must provide this fact sheet to every new patient and all patients of record only once before beginning any dental filling procedure. As the patient or parent/guardian, you are strongly encouraged to discuss with your dentist the facts presented concerning the filling materials being considered for your particular treatment.* Business and Professions Code 1648.10-1648.20
Allergic Reactions to Dental MaterialsComponents in dental fillings may have side effects or cause allergic reactions, just like other materials we may come in contact with in our daily lives. The risks of such reactions are very low for all types of filling materials. Such reactions can be caused by specific components of the filling materials such as mercury, nickel, chromium, and/or beryllium alloys. Usually, an allergy will reveal itself as a skin rash and is easily reversed when the individual is not in contact with the material. There are no documented cases of allergic reactions to composite resin, glass ionomer, resin ionomer, or porcelain. However, there have been rare allergic responses reported with dental amalgam, porcelain fused to metal, gold alloys, and nickel or cobalt-chrome alloys. If you suffer from allergies, discuss these potential problems with your dentist before a filling material is chosen.
Toxicity of Dental MaterialsDental AmalgamMercury in its elemental form is on the State of California’s Proposition 65 list of chemicals known to the state to cause reproductive toxicity. Mercury may harm the developing brain of a child or fetus. Dental amalgam is created by mixing elemental mercury (43-54%) and an alloy powder (46-57%) composed mainly of silver, tin, and copper. This has caused discussion about the risks of mercury in dental amalgam. Such mercury is emitted in minute amounts as vapor. Some concerns have been raised regarding possible toxicity. Scientific research continues on the safety of dental amalgam. According to the Centers for Disease Control and Prevention, there is scant evidence that the health of the vast majority of people with amalgam is compromised. The Food and Drug Administration (FDA) and other public health organizations have investigated the safety of amalgam used in dental fillings. The conclusion: no valid scientific evidence has shown that amalgams cause harm to patients with dental restorations, except in rare cases of allergy. The World Health Organization reached a similar conclusion stating, “Amalgam restorations are safe and cost effective.” A diversity of opinions exists regarding the safety of dental amalgams. Questions have been raised about its safety in pregnant women, children, and diabetics. However, scientific evidence and research literature in peer-reviewed scientific journals suggest that otherwise healthy women, children, and diabetics are not at an increased risk from dental amalgams in their mouths. The FDA places no restrictions on the use of dental amalgam.
Composite ResinSome Composite Resins include Crystalline Silica, which is on the State of California’s Proposition 65 list of chemicals known to the state to cause cancer.
It is always a good idea to discuss any dental treatmentthoroughly with your dentist.
Dental Materials – Advantages & DisadvantagesDENTAL AMALGAM FILLINGSDental amalgam is a self-hardening mixture of silver-tin-copper alloypowder and liquid mercury and is sometimes referred to as silverfillings because of its color. It is often used as a filling material and replacement for broken teeth.
Advantages Durable; long lasting Wears well; holds up well to the forces of biting Relatively inexpensive Generally completed in one visit Self-sealing; minimal-to-no shrinkage and resists leakage Resistance to further decay is high, but can be difficult to find in early stages Frequency of repair and replacement is low
• Refer to “What About the Safety of Filling Materials”• Gray colored, not tooth colored• May darken as it corrodes; may stain teeth over time• Requires removal of some healthy tooth• In larger amalgam fillings, the remaining tooth may weaken and fracture• Because metal can conduct hot and cold temperatures, there may be a temporary sensitivity to hot and cold.• Contact with other metals may cause occasional, minute electrical flow
COMPOSITE RESIN FILLINGSComposite fillings are a mixture of powdered glass and plastic resin, sometimes referred to as white, plastic, or tooth-colored fillings. It is used for fillings, inlays, veneers, partial and complete crowns, or to replacement for broken teeth.
Advantages Strong and durable Tooth colored Single visit for fillings Resists breaking Maximum amount of tooth preserved Small risk of leakage if bonded only to enamel Does not corrode Generally holds up well to the forces of biting depending on product used Resistance to further decay is moderate and easy to find Frequency of repair or replacement is low to moderate
• Refer to “What About the Safety of Filling Materials”• Moderate occurrence of tooth sensitivity; sensitive to dentist’s method of application• Costs more than dental amalgam• Material shrinks when hardened and could lead to further decay and/or temperature sensitivity• Requires more than one visit for inlays, veneers, and crowns• May wear faster than dental enamel• May leak over time when bonded beneath the layer of enamel
GLASS IONOMER CEMENTGlass ionomer cement is a selfhardening mixture of glass and organic acid. It is tooth-colored and varies in translucency. Glass ionomer is usually used for small fillings, cementing metal and porcelain/metal crowns, liners, and temporary restorations.
Reasonably good esthetics May provide some help against decay because it releases fluoride Minimal amount of tooth needs to be removed and it bonds well to both the enamel and the dentin beneath the enamel Material has low incidence of producing tooth sensitivity Usually completed in one dental visit
• Cost is very similar to composite resin (which costs more than amalgam)• Limited use because it is not recommended for biting surfaces in permanent teeth• As it ages, this material may become rough and could increase the accumulation of plaque and chance of periodontal disease• Does not wear well; tends to crack over time and can be dislodged
RESIN-IONOMER CEMENTResin ionomer cement is a mixture of glass and resin polymer and organic acid that hardens with exposure to a blue light used in the dental office. It is tooth colored but more translucent than glass ionomer cement. It is most often used for small fillings, cementing metal and porcelainmetal crowns and liners.
Very good esthetics May provide some help against decay because it releases fluoride Minimal amount of tooth needs to be removed and it bonds well to both the enamel and the dentin beneath the enamel Good for non-biting surfaces May be used for short-term primary teeth restorations May hold up better than glass ionomer but not as well as composite Good resistance to leakage Material has low incidence of producing tooth sensitivity Usually completed in one dental visitDisadvantages
• Cost is very similar to composite resin (which costs more than amalgam)• Limited use because it is not recommended to restore the biting surfaces of adults• Wears faster than composite and amalgam
Very little tooth needs to be removed for use as a veneer; more tooth needs to be removed for a crown because its strength is related to its bulk (size) Good resistance to further decay if the restoration fits well Is resistant to surface wear but can cause some wear on opposing teeth Resists leakage because it can be shaped for a very accurate fit The material does not cause tooth sensitivityDisadvantages
• Material is brittle and can break under biting forces• May not be recommended for molar teeth• Higher cost because it requires at least two office visits and laboratory services
NICKEL OR COBALT CHROME ALLOYSNickel or cobalt-chrome alloys are mixtures of nickel and chromium. They are a dark silver metal color and are used for crowns and fixed bridges and most partial denture frameworks.
Good resistance to further decay if the restoration fits well Excellent durability; does not fracture under stress Does not corrode in the mouth Minimal amount of tooth needs to be removed Resists leakage because it can be shaped for a very accurate fit
• Is not tooth colored; alloy is a dark silver metal color• Conducts heat and cold; may irritate sensitive teeth• Can be abrasive to opposing teeth• High cost; requires at least two office visits and laboratory services• Slightly higher wear to opposing teeth
PORCELAIN FUSED TO METALThis type of porcelain is a glasslike material that is “enameled” on top of metal shells. It is toothcolored and is used for crowns and fixed bridges
Good resistance to further decay if the restoration fits well Very durable, due to metal substructure The material does not cause tooth sensitivity Resists leakage because it can be shaped for a very accurate fit
• More tooth must be removed (than for porcelain) for the metal substructure• Higher cost because it requires at least two office visits and laboratory services
GOLD ALLOYGold alloy is a gold-colored mixture of gold, copper, and other metals and is used mainly for crowns and fixed bridges and some partial denture frameworksAdvantages
Good resistance to further decay if the restoration fits well Excellent durability; does not fracture under stress Does not corrode in the mouth Minimal amount of tooth needs to be removed Wears well; does not cause excessive wear to opposing teeth Resists leakage because it can be shaped for a very accurate fit
• Is not tooth colored; alloy is yellow• Conducts heat and cold; may irritate sensitive teeth• High cost; requires at least two office visits and laboratory services
DENTAL BOARD OF CALIFORNIA1432 Howe Avenue • Sacramento, California 95825www.dbc.ca.govPublished byCALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS