This Notice of privacy practices describes how we may use and disclose your protected health information 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 right to access and control your protected health information. "Protected health information," or "PHI," is information about you, including demographic information, that may identify you, and that relates to your past, present, or future physical or mental health condition and related health care services.
General: Your protected health information may be used and disclosed by your physician, our office staff, and others outside 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 protected 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 another physician to whom you have been referred ensure that the physician has the necessary information to diagnose or treat you or to a home health agency that provides care to you or as required.Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. 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 Operations: 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 dental school students or interns that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to 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 your protected health information, as necessary, to contact you of your appointment.
Disclosure Required by Law: We may use or disclose your protected health information in the following situations without your authorization. These situations include, as required by law, matters public health issues, communicable diseases, health oversight, abuse or neglect; Food and Drug Administration requirements; legal proceedings; matters concerning law enforcement, coroners, funeral directors, and organ donation; medical/dental research; criminal activity; military activity and national security; workers' compensation matters; and inmates required uses and disclosures. Under the 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.
You may revoke this authorization, at any time, in writing, except to the extent that your physician or physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization.
Following is a statement of your rights with the 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: psychotherapy notes; information compiled in reasonable anticipation of or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to a 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 to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations.You may also request that any part of your protected health information not to be disclosed to family members or friends who may be involved in your care or for notification purpose as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.Your physician is not required to agree to a restriction that you may request if your 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 Health care Professional.You have the right to request 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. if any, of your protected health information.We reserve the right to change the terms of this 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.
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 5, 2014. We are 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 the phone at our main telephone number.
Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:
I hereby authorize Jeanne Anne Krizman, DMD, PLC to share my dental records for myself or my dependent with the following people:
EANNE ANNE KRIZMAN, D.M.D., PLC1601 N Tucson Blvd, Suite #35Tucson, AZ 85716P: (520)326-0082/F: (520)447-7810
Thank you for choosing our office for you dental needs. We are committed to provide the highest quality of dental care available to all our patients, and to have those services comfortably affordable, we are pleased to offer you options for payment. The following is a statement of our Financial Policy which must be reviewed and signed.
As a courtesy, our office will provide you with the proper dental codes so that you may submit your insurance claims independently. Our patients generally receive reimbursement from their insurance carriers in 4-6 weeks. We are out-of network providers and therefore have no connection to your insurance plan.
PAYMENT IS DUE WHEN SERVICES ARE BEING RENDERED. Ours is a small office, and we depend on our patients paying the agreed fee when services are rendered. If you cannot pay at the time that service is rendered, you must make alternate arrangements acceptable to us before treatment begins.
We offer the following payment options:|Cash or Check Payment. Visa, Master Card, American Express, Discover, Debit. No Interest Payment Plan with Care Credit (OAC). If you intend to pay by OAC, you must make arrangements acceptable to us before treatment begins.
A $25.00 returned check fee will be billed for any returned checks.
Thank you for understanding our Financial Policy. We are here to assist you in any way possible. Please make your questions and concerns known to our team, as our goal is to ensure that you have an outstanding experience. I have read the Financial Policy. I understand and agree that:I understand that my insurance is a contract between me and my insurance company and that Jeanne Anne Krizman DMD, PLC does not file insurance claims for you. I understand that Dr. Krizman is not in network with my insurance, and authorized payment from my insurance will be paid directly to me. I understand that Jeanne Anne Krizman DMD, PLC is a fee-for-service dental-care provider. I understand that insurance is not a guarantee of payment.
Dear Valued Patient,Our purpose is to help our patients keep their teeth and gums healthy for life. Proper scheduling of appointments is vital to this endeavor. Therefore, we ask for your cooperation regarding the following appointment policy:
If you have any questions about this policy, do not hesitate to ask our office staff. We believe that good communication is key to providing you with quality dental care.