When an appointment is scheduled, that time has been reserved for you and when it is missed that time can not be used to treat another patient without sufficient notice. If an appointment is not cancelled or rescheduled at least 48 hours (weekends not included) in advance you will be charged a $100 fee. This will not be covered by your insurance company. We strive to provide excellent dental care for all of our patients. We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting a much needed treatment.

If a patient arrives past their scheduled appointment time we will have to reschedule the appointment.

We understand delays can happen however we must try to keep other patients and our providers on time.

Please note that all scheduled appointments are considered confirmed. Thank you for your understanding.

As of April 1 2003, The Helath Insurance Portability and Accountablity Act ( HIPAA) requires that we distribute to our patients a copy of our Notice of Privacy Practices. I have read and/or been offered a copy of the Notice of Privacy Practices. https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html

As of January 1 2002, the Dental Board of California now requires that we distribute to our patients a copy of the Dental Material Fact Sheet. I agree that the dental material fact sheet is available to me and can also be found on the Dental Board of California website: https://www.dbc.ca.gov/formspubs/pub_dmfs2004.pdf

Patients who carry dental insurance understand that they are responsible for any unpaid balance from dental carrier. This office will help prepare the patient's insurance forms and assist in making collections from insurance company and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by the insurance company.

In order to reduce exposure, we are requiring a card on file for payments. Your credit card is kept confidential and secure and payments to your card are processed only after a claim has been filed and processed by your insurer, and the insurance portion of the claim has paid and posted to your account. An itemized statement will be mailed to you to specify insurance payments and the patient responsibility amount charged to your card.

I grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured web site for the dental practice. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice web site with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns.

I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the web site on my behalf. I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES.

I have read the information above regarding the secured uploading of patient information to the web site for the dental practice, and grant the dental practice permission to securely upload my patient information to the web site. Also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties.
I understand the dental practice will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the web site on my behalf. I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES. I grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured web site for the dental practice.