Edgewater Dental - 3425 Highway 6 South, Ste. 108 - Sugar Land, TX 77478 - P: 832.532.7120

Appointment times are reserved for you alone. When you make an appointment, please be sure that you are able to keep it. Please not that these policies may result in additional charges incurred within the office and are not covered by your insurance.

 

No Show Policy

A "no show" is an appointment that was not cancelled in advance, no show inconveniences other patients who need dental care and can cost the practice a lot of money by having the doctor and staff idle. This ultimately increases costs for everyone. A no show for a scheduled appointment will therefore result in the following fee:

• Cleaning/Preventative Appointments - $50 flat fee
• Basic/Major Appointments - $50 for every half hour scheduled
• Surgery Appointments -  see separate surgery policy

Surgery Appointment Policy

There is a $200 scheduling deposit to secure your desired appointment date and time. Patient is eligible for a FULL REFUND if appointment is cancelled 5 days BEFORE surgery date. Rescheduling/Cancellation within 5 days of surgery date with result in the forfeit of deposit. If you wish to reschedule once you have cancelled within 5 days of your surgery date, there will be another $200 non-refundable deposit, necessary to secure your new surgery date.

Rescheduling/Cancellation Policy

There will be a charge of $50 for rescheduling or cancellation of an appointment within less than 24 hours of your appointment.

A $25 fee will be assess when dental records, including diagnostic x-rays, are requested by the patient and are not being transferred to another healthcare provider for continuity of care. All dental records requests require 2-3 business days for processing. There is also a $25 fee for FMLA or other work related forms, and personal disability (non-federal) forms.

Edgewater Dental - 3425 Highway 6 S, Ste. 108 - Sugar Land, TX 77478 - P/832.532.7120 - F/832.532.7637

We are committed to providing our patients with the best care possible. We would like you to be informed of our office financial and insurance policy. Payments are expected at the time services are rendered. If you have dental insurance, we are happy to help you receive your maximum allowable benefits only for the services performed. To maintain the practice operation and to prevent potential misunderstanding, we ask patients to accept and adhere to financial arrangements regarding their dental treatment.

We accept cash, MasterCard, Visa, Discover, and American Express. In addition, we offer an excellent third party financial payment plan for balances over $600.00. Our office staff would be happy to provide you with more detailed information on this plan if you are interested. If you pay with a personal check, it would have to be approved by Telecheck before being taken as a payment, and if returned, a $35.00 bank processing fee will be applied.

If you have dental insurance, please provide us with complete insurance information, and we will help you process your insurance claim for reimbursement as a courtesy to you. We accept assignment of insurance benefits; however, please be aware of the following:

1. Your insurance is a contract between you, your insurance carrier and your employer. WE ARE NOT PARTY TO THAT CONTRACT; THEREFORE, OUR FINANCIAL RELATIONSHIP IS WITH YOU, NOT WITH YOUR INSURANCE COMPANY.
2. All changes are your responsibility whether your insurance company pays or not. Not all services are covered benefits in all contracts. Some insurance companies arbitrarily select certain services they will not cover.
3. Fees for these services, along with unpaid deductibles and co-payments are due at the time of treatment.
4. If the insurance company does not pay your balance in full within 60 days, we will be require you to pay the balance due with cash, MasterCard, Visa, Discover, or American Express.
5. If your insurance overpays us, we are to receive payment by such before providing you with a refund amount. Amount cannot exceed the monies you have currently paid for that service.

We must emphasize that as dental care providers, our relationship is with you the patient, not your insurance. We realize that temporary financial problems may affect timely payments of your account; if such situations do arise, we encourage you to contact us promptly for assistance in the management of your account. If you have any questions about the above information, please do not hesitate to ask us. We are here to assist you with any questions or concerns you may have.

Edgewater Dental - 3425 Highway 65, Ste. 108 - Sugar Land, TX 77478 - P/832.532.7120 - F/832.532.7637

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.

We are required aby applicable federal and state law to maintain the privacy of your health information. We are also required 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. The notice takes effect 01/01/2014 and will remain in effect until we replace.

We reserve the right to change our privacy practices and the terms of the 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 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 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 heath information to a physician and other healthcare providers providing treatment to you.
• Payment- We may use and disclose health information to obtain payment for services we provide to you.
• Healthcare Operations- We may use and disclose your health information in connection with your healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualification of healthcare professionals, evaluating practitioner and provider
  performance, conduction 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 ue if 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 your health information to you, as described in the Patients’ 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 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 incapacity or emergency circumstances, we will disclose health information based on a determination using professional judgement 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 practices 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 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, or domestic violence of 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 of others.
• National Security- We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorize federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institutions of law enforcement officials 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, emails, text messages, 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 will also request access by sending us a letter to the address at the end of this Notice. 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 our fee structure.
• Disclosure Accounting- 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 months, but not before January 2014. 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 required to agree to these additional requests, 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 of 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 website or by 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 the use of disclosure of your health information or to have us using the contact information listed at the end for this Notice.

We support your right to the privacy of your health information.

Contact Officer: Ali Sajadi, DDS, MSD

Address: 3425 Highway 6 South, Ste. 108, Sugar Land, TX 77478

 

Phone: 832-532-7120                    Email: edgewaterdentaltx@gmail.com

Edgewater Dental - 3425 Highway 6 S, Ste. 108 - Sugar Land, TX 77478 - P/832.532.7120 - F/832.532.7637

Patients with dental insurance must provide accurate and complete insurance information so we may assist you in filing your dental claims promptly. You will be required to pay your estimated portion the day of treatment. Remember that professional services are rendered and charged to the patient and not the insurance company.

Insurance reimbursement is a contract between you and your carrier. You are responsible for payment of your account within the usual limits of our credit policy. If your insurance does not pay within 60 days, we shall expect payment in full from you.

If you have any questions, we will assist you. Your eventual reimbursement will be determined by your insurance

Assignment of Insurance Benefits: I hereby authorize Edgewater Dental to submit claims to my insurance carrier for all services rendered. I direct third party payers (insurance companies) to issue payment directly to Edgewater Dental.

Authorization to Release Information: I authorize the release of any information concerning my or my child's healthcare, advice, and treatment provided for the purpose of evaluating and administering claims for insurance benefits.

Financial Responsibility: I understand that this is my responsibility to provide complete, accurate and timely information on my insurance coverage. In the event that my insurance coverage does not pay, for any reason, I understand that I will be financially responsible for the dental services.

I understand that I am responsible for all costs of dental treatment, whether or not paid by my insurance. I authorize the use of my signature on all insurance submissions.

Edgewater Dental - 3425 Highway 6 South, Ste. 108 - Sugar Land, TX 77478 -P/832.532.7120 F/832.532.7637 -