Name of Friend/Family that referred you: Type name here
If Yes, the Guardian or Responsible Party will need to complete a additional information.
To the extent permitted by law, I consent to Cornerstone Family Dentistry (or their designees) use and disclosure of my Protected Health Information to carry out payment activities in connection with my insurance claim. This information will be used exclusively for the purpose of evaluating and administering claims for benefits. I further authorize and direct payment to my practice of the dental benefits otherwise payable to me.
I authorize the disclosure of information from my treatment records to:
A Clear, Written Estimate on the Cost of Treatment
We will provide you with a comprehensive treatment plan after assessing your overall oral health. We will provide a clear, detailed estimate on the cost of your treatment plan in writing, so you know what to expect, including your estimated insurance benefits. If you have any questions related to your insurance coverage, we encourage you to contact your insurance company.
Payment in full of the Patient Financial Responsibility amount, as specified in your treatment plan, is due no later than when services are rendered. For comprehensive treatment plans requiring multiple office visits, you will be required to pay for the services received at each specific office visit. You may, at your discretion, elect to pay in full, in advance for comprehensive treatment plans.
If you have dental insurance, and we are a participating provider with your insurance, you will be billed pursuant to the terms of your dentist’s agreement with your insurer. If your dentist is not a participating or in-network provider with your insurance plan, we will honor our in-office fee schedule.
Cornerstone Family Dentistry accepts payment from non-affiliated, third party finance companies. Credit decisions are the responsibility of these third-party finance companies. You may choose to pay all or a portion of your treatment using approved third-party financing products.
We require that you give our office 24 hours’ notice if you need to reschedule your appointment. This allows for other patients to be scheduled into that appointment. If you miss an appointment without contacting our office within the required time, this is considered a missed appointment. A fee of $25.00 will be charged to you; this fee cannot be billed to your insurance company and will be your direct responsibility. No future appointments can be scheduled without the payment of this fee. Additionally, if a patient is more than 20 minutes late without prior notice for a scheduled appointment, we will consider a missed appointment and the $25.00 cancellation fee will be charged.
We would like to keep in touch regarding your upcoming appointments, treatment plan, treatment status, pricing, and billing status. By providing your email address, phone number, and mailing address, you are giving Cornerstone Family Dentistry permission to contact you through one or all these communication methods. Note that email and text messaging is not secure and there is a risk that they could be read by a third party. By sharing your email or mobile number with us you are acknowledging that you are aware of this risk and agree to receive this type of communication. Cornerstone Family Dentistry will limit the type of information in the messages.
This notice describes how health information about you may be used and disclosed and how you can get access to this information—Please review it carefully.
Uses and disclosures of health information
The following describes how information about you may be used in this dental office:
• Treatment Services: We may use or disclose your health information to all our staff members, other dentists, your physicians, and/or other health care providers taking care of you. • Payment and Health Care Operations: We may use or disclose your health information to obtain payment for services we provide to you, to participate in quality assurance, disease management, training, licensing, and certification programs. Upon your written request, we will not disclose to your health insurer any services paid by you out of pocket. • Marketing/Fundraising: We will not use your health information for marketing or fundraising purposes without your written consent. You can opt out of receiving information about our marketing or fundraisers. We will not sell your health information without your explicit authorization. • Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders such as voicemail messages, text messages, emails, postcards, or letters. • Legal Requirements: We may use or disclose your health information when required to do so by law. • Abuse or Neglect: If abuse or neglect is reasonably suspected, we may use or disclose your health information to the appropriate governmental authorities. • National Security: When required, we may disclose military personnel health information to the Armed Forces. Information may be given to authorized federal offices when required for intelligence and national security activities. Health information for inmates in custody of law enforcement may be provided to correctional institutes. • Family Members, Friends, and Others Involved in Care: At your request, we may disclose your health information to a family member or other person if necessary, to assist with your treatment and/or payment for services. Based on our judgement and as per 164.522(a) of HIPAA we may disclose your information to these persons in the event of an emergency. We also may make information available so that another person may pick up filled prescriptions, medical supplies, records, or x-rays for you. Your information may be disclosed to assist in notifying a family member, caregiver, or personal representative of your location, condition, or death. • Business Associates: Some services in our organization are provided through contacts with business associates. Examples include practice management software representatives, accountants, answering service personnel, etc. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we have asked them to do and bill you or your third-party payer for services rendered. All our business associates are required to safeguard your information and to follow HIPAA Privacy Rules. • Workers' Compensation: We may release medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illnesses. • Research: We may use or disclose medical information to researchers when an institution's review board or special privacy board has reviewed the proposed study and established protocols to ensure the privacy of the health information used in their research and determined that the researcher does not need to obtain your authorization prior to using your medical information for research purposes. • Public Health Activities: We may use or disclose your health information for public health activities, to include the following: to prevent or control disease, injury, or disability; to report reactions with medications or problems with products, to notify people of recalls of products they may be using; to notify a person who may have been exposed to a disease or who may be at risk for contracting or spreading a disease of condition; to notify the proper government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence (when required by law). • Other Authorizations: In addition to our use of your health information for treatment, payment, or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us authorization, you may revoke it at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. • Breach Notification: We will notify you any time your PHI may have been compromised through unauthorized acquisition, use or disclosure.
Patient Rights • Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. We will charge you a reasonable cost-based fee for expenses such as copies. If you request X-Rays, there will be a fee for any copies of films. You are not entitled to originals, only copies. Postage will be added if copies are to be mailed. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Details of all fees are available from the HIPAA Coordinator. • Accounting of Disclosures: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. • Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We will keep your information confidential from your health plans if you pay cash, at your request. In some instances, we may not be required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). • Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location and provide satisfactory explanation how payments will be handled under the alternative means or location you request. • Amendment: You have the right to request that we amend your health information. (Your request must be in writing and must explain the reason for the amendment.) We may deny your request under certain circumstances.
We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the HHS.
HIPAA Coordinator – Whitney Wilson Phone – (615)333-3382 • Fax – (615)832-1293 • Email – Info@CornerstoneDentistryNashville.com • Address – 404 Welshwood Drive, Nashville, TN 37211