I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This provides a safeguard to my privacy.
What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your protected Heath Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPPA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov
We have adopted the following policies:
- Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient record, PHI and other documents or information.
- It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S. mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policies and new technologies that you may find valuable or informative.
- The practice utilizes a number of vendors in the conduct of business. These vendors may have access to the PHI but must agree to abide by the confidentiality rules of HIPAA.
- You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
- You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
- Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
- We agree to provide patients with access to their records in accordance with state and federal laws.
- We may change, add, delete or modify any of these provisions to better serve the needs of both the practice and the patient.
- You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI.
However, we are not obligated to alter internal policies to conform to your request.
NOTIFICATION/COMMUNICATION WITH FAMILY
We require a parent or legal guardian to accompany their child (if patient is under the age of 18) to the initial orthodontic visit with us. This assures that you have accurate information of our treatment plan and know what the upcoming appointments entail.
We understand there may be circumstances when you are unable to accompany your child after their initial appointment. We may disclose information to a family member, other relative, or any other person you identify as responsible for your/your child’s treatment information or payment related to your/your child’s care.
PATIENT RESPONSIBILITY
Elite Orthodontics provides exceptional and specialized orthodontic care for children and adults. We are excited to have your family as part of the practice!
To ensure that care is completed in a timely fashion, it is important to keep scheduled visits with our office. If you need to make changes to an upcoming appointment, we ask that you do so at least 48 hours in advance by notifying our office via phone call, text, or email.
Late cancellations are considered as any cancellation within a 24 hour period. Please call our office if an urgent change to an appointment is required. We understand things come up! Communication ensures staying apart of this practice and excessive history of late cancellations may result in dismissal from the practice.
Failed appointments occur when a patient misses their scheduled appointment and there was no effort made to contact our office prior to the appointment. Failed appointments disrupt the timeline of treatment and level of care we can provide.
Late cancellations and failed appointments are subject to a fee up to $100.
BILLING AND PAYMENT EXPECTATIONS
Payment is due at time of service unless a prior arrangement has been made with our office. This includes co-payments, co-insurance, and payment for uncovered services.
Dental insurance may cover a portion of treatment. If you would prefer a prior authorization be submitted to your dental insurance provider, please let our office know.
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 options.
I assign directly to Elite Orthodontics, LLC all insurance benefits, if any, otherwise payable to me for services rendered. I understand that the insurance amount is only an estimate and I am financially responsible for all charges whether or not paid by insurance. I understand that I must keep the insurance coverage in effect during the treatment period to be eligible for the insurance benefit amount. I hereby authorize Elite Orthodontics to release all information to secure payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.