511 S. Fountain Green Road
Bel Air Maryland 21015

Phone (410)-879-1730  

I understand that I am responsible for payment of services rendered, co-payments and deductibles that my dental insurance does not cover. Co-payments and deductibles are due at the time of service. If payment is not received within 30 days from date of service, you will be assessed a 1.5% late charge of your unpaid balance or a $ 5.00 billing fee, whichever is greater, until balance is paid in full. Our contractual arrangements are with you are not your insurance company. Any checks returned will be subject to a $40.00 returned check fee. If your account becomes assigned to a collection agency, I agree to pay the cost of collection agency fees, court costs, and attorney fees.

I authorize the dentist to release any information requested by any third-party payor regarding charges incurred by the patient. I consent to all treatment, tests, and diagnostic procedures deemed necessary by the dentist. Absolutely no dental treatment will be started without my prior approval.

Any appointment cancelled less than 48 hours in advance will be charged a cancelled appointment fee of $67.00 which is not covered by insurance.

Any Scheduled appointment that the patient fails to appear without notice will be charged a missed appointment fee of $67.00 which is not covered by insurance.

I have read the above; I understand it and agree to the terms.

Dear Patient:

In an effort to provide you with payment arrangements, we have expanded our payment policy

FULL PAYMENT ARRANGEMENTS ARE
REQUESTED AT THE TIME OF YOUR VISIT

Please make a choice, sign below and return to the office manager before treatment.

Our office is a fully approved and accredited user of the Visa and MasterCard Health Care Program which will enable you to use your Visa and MasterCard to automatically cover amounts not paid by your insurance.

If none of the above applies, please see the office manager.

Dear Patient:

In an effort for Dr. Kreiner’s office to contact you to confirm appointments, follow up after a procedure or to remindyou of overdue. recare or treatment.

Please mark the line on how you would like to be contacted.Please feel free to choose as many as you like:

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, 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 activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. 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 of Privacy Practices, including any revisions of our Notice, at any time by contacting:

• Contact Person: Nancy
  
  
• Phone: (410)-879-1730
  
  
• E-mail: office@bartkreinerdds.com
  
  
• Address: 511 South Fountain Green Road, BelAir, Maryland #21015
  
  

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation.

submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

I {childsName} , 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 and health care operations.

If this Consent is signed by a personal representative on behalf of the patient, complete the following:

I, {childsName} have received a copy of this office's Notice of Privacy Practices.

All Rights Reserved

Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.

This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002)

We are required by 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. This Notice takes effect 04/14/2003, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this 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 privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

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 professionals, evaluating practitioner and provider performance, conducting 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 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 your 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 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 the 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 judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and our experience with common practice 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 or 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 or the 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 authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institutions or law enforcement official having lawful custody of protected health information of inmates or patients under certain 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 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 may also request access by sending us a letter to the address at the end of this Notice. If you request health information copies in your dental records call the office for current charge to do so. 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 disclosed your health information for purposes other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. 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 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 a 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 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 Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

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 or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may 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. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact Officer: Nancy
Phone: (410)-879-1730 
E-mail: office@bartkreinerdds.com

We will not trade, sell, share or rent your personal information to outside parties

1. Business Associates: It may be necessary for Dr. Kreiner’s office to disclose your health information to a business associate in order for them to perform a service for our business operations.
   
   
2. Patient-Related Communications: It may be necessary for Dr. Kreiner’s office to use or disclose your health information in order to provide patient related communications. This would include things such as intraoral photography, and phoned in prescriptions.
   
   
3. Personal Information Voluntarily Submitted: If you choose to share your personal information with Dr. Kreiner’s office such as a “contact us” form leaving a comment, sending an email or completing a survey, it may be necessary for Dr. Kreiner’s office to use that information to respond to you so that we can get the information or services you have requested.
   
   
4. Interaction With Children Online: We take reasonable steps necessary to protect the privacy of children as required by the Children’s Online Privacy Protection Act (COPPA). The consent of a child’s parent or guardian is required before Dr. Kreiner’s office will collect, use or share personal information of a child under the age of 13. Dr. Kreiner’s office does not knowingly collect information from anyone under the age of 13.
   
   
5. Analytics: We work with companies such as Webixis, Call Rail, and other technology companies gathering analytics and advertising our products and services.
   
   
6. Cookies: We may use cookies to collect and store information that enables the site or systems to recognize your browser and remember certain information. These cookies are used to compile data site traffic and site interaction so that we can approve the site experience in the future.