PRIVACY PRACTICES
In accordance with the Privacy Regulations created by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) we are required to maintain the confidentiality of your health information. We realize that these laws are complicated, but we must provide you with the following important information that describes how we may use and disclose your protected health information to carry out treatment, payment of health care operation, and for other purposes that are permitted or required by law.
We will use or disclose your protected health information to provide, coordinate, or manage your dental care and any related services. For example: your health/dental information may be provided to a dentist to whom you have been referred to ensure that the dentist has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information periodically to another dentist, physician, or health care provider who becomes involved in your care.
We may use and disclose dental information about you in order to obtain payment for services rendered. Such disclosures may be made to you, an insurance company, responsible party, or third party. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover treatment.
APPOINTMENT AGREEMENT
We are honored to provide you with your dental hygiene needs and are committed to providing quality service to all of our patients. We reserve enough time for each client and their specific needs. An important aspect to delivering exceptional care is your commitment to keeping your reserved appointment as scheduled. Therefore, we ask that you respect our time by being present and available at the appointment time as scheduled.
Should you change your appointment for any reason we ask that you give us 48 business hours notice to avoid a cancellation charge of $100.00.
All charges are your responsibility from the date of the services rendered and payment is due at time of service.
ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES AND APPOINTMENT AGREEMENT: