Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medications that you may be taking, could have an important interrelationship with the dentistry you will receive. Please answer all the following questions truthfully and to the best of your ability. Thank you.
WOMEN: Are you:
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any future changes in medical status.
Welcome to Presidio Dental! The following questions will help us get to know you better:
8740 N. Thornydale Rd., Ste 100Tucson, AZ 85742(520)744-7388; Fax: (520)email@example.com
THIS NOTICE DESCRIBES HOW PERSONAL AND 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 legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This notice describes how we protect your health information, your personal information and what rights you have regarding it.
TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
The most common reason why we use or disclose your health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you; examining your teeth; prescribing medications and faxing or calling them in to be filled; referring you to another doctor for other health care or services; or getting copies or your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health or dental care plans or other sources of payment; preparing and sending bills or claims which will include identifying information; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). "Health care operations" mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and storage of records.
We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside of our office for these reasons, we will ask you for special permission.
USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION
In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:
Unless you object, we will also share relevant information about your care with family or friends who are helping you with your dental care.
We may call, text, email or write to remind you of scheduled appointments, or that is time to make a routine appointment or to follow up on unscheduled treatment. We may also call, text, email or write to notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise, we will mail you a reminder on a postcard, send an email, text message you, and/or leave you a reminder message on your voicemail or with someone who answers your phone if you are not home. Unless you tell us otherwise, we may send out correspondence such as Newsletters, post-op instructions, and promotions via email. You will have the opportunity to opt-out of any digital correspondence through email and/or text message.
OTHER USES AND DISCLOSURES
We will not make any other uses or disclosures of your health information unless you sign a written "authorization form." The content of an authorization form is determined by federal law. Sometimes, we may initiate the authorization process, and other times you may initiate the process if it's your idea for us to send your information to someone else. Typically, in this situation, you will give us a properly completed authorization form, or you can use one of ours.
If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the office contact person named at the beginning of this notice.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
The law gives you many rights regarding your health information. You can:
OUR NOTICE OF PRIVACY PRACTICES
By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by 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 in our office, have copies available in our office, and post it on our website.
If you think that we have not properly respected the privacy of your health information, you are free to file a complaint to 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 the address, fax or email shown at the beginning of this notice. If you prefer, you can discuss your complaint in person or by phone.
FOR MORE INFORMATION
If you want more information about our privacy practices, call or visit the office contact person at the address or phone number shown at the beginning of this Notice.
We believe in the importance of quality dental care and always strive to provide the best treatment possible. Also, we understand the financial limitations that influence your choice of care. We want to assure you of our flexible approach to financing. We work with most insurance companies and always try to maximize your coverage through meticulous detailing of procedures and interaction with your insurer. We even submit all your claims for you and are available to answer any questions we can.
Payment and Scheduling:
Please remember that if you are using insurance, you are responsible for the portion not covered by your plan. Because we, too, must balance our finances, we do ask that you pay your portion in full before beginning treatment. For minor work such as fillings, your patient portion is required at the time of scheduling your appointment. For major services, we ask that 50% of your portion is paid at scheduling to reserve your treatment time, and the remaining balance is due at your appointment before the procedure begins. Or, if it works better for you, you may use CareCredit (medical-only financing) for any services, which will allow you to make monthly payments with no money down. For your convenience, we also accept major credit cards and personal checks ($25 fee for returned checks). In the event that your insurance denies your claim, you will be financially responsible for all completed treatment. An account 3 months past due will be transferred to recovery, and a $25 billing charge will be assessed at that time.
Cancellations and Rescheduling:
We understand that rescheduling or canceling your appointment sometimes becomes unavoidable. We do ask that you provide at least 48 hours' notice. Please note there is a $50 per hour fee for late reschedules, cancellations, or no-show appointments.
We hope that you find this information useful. Rest assured that we are here to help make high-quality dental care obtainable to all. We look forward to working with you to achieve excellent dental health!
Jesse C. Engle, DMD