FINANCIAL ARRANGEMENTS:

It is our desire to hold our cost to you, our patient, as low as possible. In order to do this, we must have a constant cash flow in our business. For your convenience, we accept cash, checks and major credit cards. For major services, including fabrication of dentures and partial dentures, our office requires payment of ONE-HALF down at the time the impressions are taken and the balance to be paid prior to delivery of the dentures. All other services require payment at the time services are rendered. If this presents a problem to you, please let us know and we will be happy to reschedule you for a more convenient time.

INSURANCE AUTHORIZATION & BILLING INFORMATION:

We bill insurance as a courtesy to our patients. Patients who carry dental insurance understand that all services will be charged directly to the patient prior to the completion of treatment. Insurance is billed as a reimbursement to the patient at the end of the treatment period. It is understood that the patient/responsible party agrees to be fully responsible for the payment of services. Please note, all claims are submitted with no guarantee of payment.

I have read and accept the terms and conditions outlined above by WestCoast Digital Denture and Implant Center as it relates to payment for services. I agree to be fully responsible for the payment of services provided to me by WestCoast Digital Denture and Implant Center. If applicable, I give WestCoast Digital Denture and Implant Center permission to submit dental claims for services on my behalf. To the extent permitted by law, I consent to your use and disclosure of my protected health information to carry out payment activities in connection with any claims.

NOTICE OF PRIVACY PRACTICES:

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.


We respect our obligation to keep your health information private. We are obligated by law to give you notice of our privacy practices. This notice describes how we protect your health information and what rights you have regarding it.

USES AND DISCLOSURE OF HEALTH INFORMATION:

We may use and disclose your health information to a denturist, dentist, or other health care provider for treatment purposes. We may use and disclose your health information to bill and collect payment for services we provide to you. Within our professional judgement and unless you object, we will share relevant health and dental information with family and friends assisting in your care.

We will not use your information for marketing without your writted authorization. We will disclose your health information when required by federal, state, or local law authorities or legal processes such as, but not limited to subpoena, court order, warrants, or summons. We may disclose your information to appropriate authorities if we reasonably suspect you are a victim of a possible crime so as to avert serious threat to your safety and the safety of those around you. We may use your information to provide appointment reminders, such as, but not limited to post cards, voicemail, letters, text, or email.

PATIENT RIGHTS:

You have the right to look at or get copies of your health information with limited exceptions. This request may be send in writing to one of the addresses listed above via certified mail. You will charged a reasonable fee for copies, postage, and staff time. You may have the right to place additional restrictions on usage or disclosure or your health information. We are not required by law to agree these restrictions. To the best of our ability, we will abide by restrictions except in the event of an emergency in our professional opinion. You may request alternate means or locations of which to discuss your information. This must be presented in writing with a satisfactory explanation and detailed format of how payments will be handled under the alternate means or location you request. You have the right to amend your health information in writing and it must explain why the amendment is to take place. We may deny your request under certain circumstances.

By law we must abide by the terms of the Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by the law. If we change this notice, the new privacy practices will apply to your health information that we already have, as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice and have copies available in our office.

COMPLAINTS:

If you think we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at one of the addresses listed at the top of this notice.

At WestCoast Digital Denture and Implant Center we believe in denture care that is founded upon excellence and quality. We seek to accomplish this, in part, by being on time and prepared for every patient appointment. We feel this will cause minimal disruption to your daily schedule and will provide as much efficiency as possible in completing your denture treatment.

 Office hours are by appointment only. This office provides private, personal denture care. Appointment time is reserved for you alone.

 When you make an appointment with us, please be sure that you will be able to keep it. We understand that emergencies and unforeseen treatment problems may arise, causing schedule changes. We always try our best to ensure these circumstances do not inconvenience other patients and we appreciate your understanding of those situations.

 As a courtesy, our office will call in an attempt to confirm your appointment the day before it is scheduled (we call on Friday for Monday appointments).

If you cannot make an appointment as scheduled, please notify the office. Please be aware that if you arrive more than 15 minutes late to your scheduled appointment you may be asked to reschedule. There will be a charge of $75 for missed appointments or appointments that are not canceled with more than a 24 hour notice. Patients who break appointments may also be required to prepay for future treatment.

If you have any questions about our appointment cancellation policy, please let us know!

We are required to provide you with a copy of our Notice of Privacy Practices which states how we may use and/or disclose your health information. If you are filling out online paperwork, you will receive a copy at your next appointment or by email.

By signing this form, I acknowledge that I have signed and received a copy of this office’s Notice of Privacy Practices for my own records. I also acknowledge that I have signed and received a copy of the Financial Arrangements/Insurance Authorization & Billing Information for my own records.

I understand that signed copies of these forms have been scanned into my digital chart for documentation purposes.