Notice of Privacy Practices

In the course of providing service to you, we create, receive, and store health information that identifies you. I understand that, under the Health Insurance Portability & Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, Plan, and Direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly
• Obtain payment from third-party payers (e.g. my insurance company)
• Conduct normal healthcare operations such as quality assessments and physician certifications

The Notice of Privacy Practices you have been given describes these uses and disclosures in detail. You are free to refer to this notice at any time before you sign this form. As described in our Notice of Privacy Practices, the use and disclosure of your health information for treatment purposes not only includes care and service provided here but also disclosures of your health information as may be necessary or appropriate for you to receive follow-up care from another health professional. Similarly, the use and disclosure of your health information for purposes of payment includes:

• Our submission of your health information to a billing agent or vendor for processing claims or obtaining payment
• Our submission of claims to third-party payers or insurers for claims review, determination of benefits and payment
• Our submission of your health information to auditors hired by third-party payers and insurers

Other aspects of payment described in our Notice of Privacy Practices. Our Notice of Privacy Practices will be updated whenever our privacy practices change. You can receive an updated copy of this notice from our office.

You have the right to ask us to restrict the uses or disclosures made for purposes of treatment, payment, or healthcare operations, but as described in our Notice of Privacy Practices, we are not obliged to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how to ask for a restriction.

Financial Policy

We are committed to providing you with the best possible dental care. Our fees reflect our professional commitment to excellence. In order to achieve these goals, we need your assistance and understanding of our financial policy. For the convenience of our patients, we accept payments as detailed on the patient information page of our website.
If you have dental insurance, we are happy to help you receive your maximum allowable benefits. However, it is important for you to realize the following:

• Your dental insurance policy is a contract between your employer and the dental insurance carrier. ((PRACTICENAME)) is not a part of that contract
• While we are happy to look into your insurance benefits for you and file claims on your behalf, this is done as a courtesy for you. You are ultimately responsible for understanding your insurance benefits prior to treatment. Balances due to insurance denials are the patient’s responsibility regardless of the reason for the denial.
• We do accept assignment of benefits from your insurance. Therefore, you will be given an estimate of how much we expect the insurance to pay and how much your anticipated out-of-pocket will be. We will collect your anticipated out of pocket expense at the time of services. However, ultimately the full cost of treatment is the responsibility of the insured, not the insurance company.
• Please be aware that when bringing in a minor for treatment, the parent or guardian bringing the child in is responsible for any payment due for that child on the day of service.
• As stated above, we do accept assignment of benefits from your insurance company as a courtesy to you. By signing below, you state that you are aware of this and authorize your insurance company to issue payment directly to ((PRACTICENAME)) on your behalf
•  A finance fee may be charged to balances over 90 days past due.

Reserved Appointment Policy

We are committed to providing you with the best possible dental care. Our fees reflect our professional commitment to excellence. In order to achieve these goals, we need your assistance and understanding of our financial policy. For the convenience of our patients, we accept payments as detailed on the patient information page of our website.
If you have dental insurance, we are happy to help you receive your maximum allowable benefits. However, it is important for you to realize the following:

• Your dental insurance policy is a contract between your employer and the dental insurance carrier. ((PRACTICENAME)) is not a part of that contract.
• While we are happy to look into your insurance benefits for you and file claims on your behalf, this is done as a courtesy for you. You are ultimately responsible for understanding your insurance benefits prior to treatment. Balances due to insurance denials are the patient’s responsibility regardless of the reason for the denial.
• We do accept assignment of benefits from your insurance. Therefore, you will be given an estimate of how much we expect the insurance to pay and how much your anticipated out-of-pocket will be. We will collect your anticipated out of pocket expense at the time of services. However, ultimately the full cost of treatment is the responsibility of the insured, not the insurance company.
• Please be aware that when bringing in a minor for treatment, the parent or guardian bringing the child in is responsible for any payment due for that child on the day of service.
• As stated above, we do accept assignment of benefits from your insurance company as a courtesy to you. By signing below, you state that you are aware of this and authorize your insurance company to issue payment directly to ((PRACTICENAME)) on your behalf.
•  A finance fee may be charged to balances over 90 days past due.

By signing this form I understand that the information I have given above is correct to the best of my knowledge, that it will be held in the strictest of confidence, and that it is my responsibility to inform the office of any changes to this information. I also authorize the dental staff to perform the necessary dental services I may need.