Please list 2 contact name to whom the practice can release PHI information (HIPAA).

The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment. As consistent with applicable laws and the policies of the patient’s applicable dental insurance or other third-party payer coverage, we agree to the following:

All emergency dental services and any dental services performed without previous financial arrangements must be paid for in cash at the time services are rendered.

All dental services are charged directly to the patient and the patient is personally responsible for payment of all dental services, even if the patient carries dental insurance. The office will as a courtesy, help prepare the patient’s insurance forms and assist in making collections from dental insurance companies, and will credit any collections to the patient’s account.

Fee estimates for dental care can only be extended for a period of six months from the date of consultation.

Payment for services is due at the time of treatment, or if billed by this office, payment is due within thirty (30) days of billing.

Charges for services shall be billed unless otherwise notified by the patient, in writing, within the time payment is due.

I understand the above information and agree with its contents, and this will serve as my electronic signature.

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program requiring all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.

The following is an explanation of how we are required to maintain the privacy of our health information and how we may use and disclose your health information.

We may use and disclose your medical records solely for each of the following purposes: treatment, payment, and health care operations, and when required by law.

Treatment means providing coordination or managing health care and related services by one or more health care providers, consultation between health care providers relating to a patient, or referral of a patient for health care from one provider to another. For example, we may use and disclose your medical information to a specialist for treatment purposes. Payment means such activities as obtaining reimbursement for services, confirming coverage, billing, or collection activities and utilization review. For example, sending a bill for your visit to your insurance company for payment. Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

You have the following rights with respect to your protected health information, which you may exercise by presenting a written request to our Privacy Officer:

You have the right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it. The right to reasonable requestst to receive confidential communications of protected health information from us by alternative means or at alternative locations. The right to inspect and copy your protected health information. The right to amend your protected health information. The right to receive an accounting of disclosures of protected health information. The right to obtain a paper copy of this notice from us upon request. Thank you for your attention to this matter.

I understand the above information and agree with its contents, and this will serve as my electronic signature.