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PATIENT CONSENT FORM

  • 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.


  • Dental Practice Name: Modern Restorative Dentistry


  • Our Legal Duty

  • We are required by law to maintain the privacy of your protected health information (PHI), provide you with this Notice of our legal duties and privacy practices, and follow the terms of the Notice currently in effect.


  • Uses and Disclosures of Health Information

  • We may use and disclose your health information for the following purposes:

  • Treatment

    We may use or disclose your health information to provide, coordinate, or manage your dental care and related services. This includes consultation with other healthcare providers involved in your care.

    Healthcare Operations

    We may use and disclose your health information for practice operations, including quality assessment, staff training, licensing, and business management activities.

    As Required by Law

    We may disclose your health information when required to do so by federal, state, or local law.

    Public Health and Safety

    We may disclose health information for public health activities, reporting abuse or neglect, preventing serious threats to health or safety, and other situations permitted by law.

    Business Associates

    We may disclose your health information to third parties who perform services for our practice, provided they agree to protect the privacy of your information.


  • Dental Insurance and Financial Arrangements

  • Payment for services is due at the time services are rendered, unless payment arrangements have been approved in advance.
    If you have dental insurance we will work hard to help you receive your maximum allowable benefit. In order to achieve this goal we need you to take the necessary steps to understanding your insurance plan. There being so many different providers and plans, it is impossible for us to know all of our patient’s benefits. It is very important for you as a dental insurance policy holder, to be aware of the plan benefits, deductibles, and exclusions. Plan benefits can be obtained by calling your dental insurance company. We will gladly discuss your proposed treatment and answer any questions that you may have relating to your insurance. You however, must be aware that:

  • 1. Your insurance is a contract between you, your employer and the insurance company. We are not a part of that contract.
    2. Most insurance companies have a yearly deductible that is your responsibility to pay.
    3. Most insurance companies only pay a percentage of the cost (such as 50% or 80%) and you will be responsible for the remainder.
    4. Not all services are a covered benefit in all contracts. It is important for you to contact your insurance provider and ask if there are any clauses or waiting periods.
    5. As a courtesy to you, our office will submit claims to your insurance provider; if for any reason the claims go unpaid you will be responsible for all charges.

  • If you have any questions regarding this information, or any uncertainty regarding insurance coverage please don’t hesitate to ask us, we are here to help you in any way we can.


  • Other Uses and Disclosures

  • Substance use disorder treatment records or testimony relaying the content of such records shall not be used or disclosed in civil, criminal, administrative, or legislative proceedings against the individual unless based on written consent, or a court order after notice and an opportunity to be heard is provided to the individual or the holder of the record. A court order authorizing use or disclosure must be accompanied by a subpoena or other legal requirement compelling disclosure before the requested record is used or disclosed.


  • Your Rights

  • You have the right to: - Inspect and obtain a copy of your health records - Request an amendment to your health information - Request restrictions on certain uses and disclosures - Request confidential communications - Receive an accounting of disclosures - Receive a paper copy of this Notice upon request


  • Complaints

  • If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer or with the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint.


  • Changes to This Notice

  • We reserve the right to change this Notice. Any changes will apply to all health information we maintain. The revised Notice will be available upon request and in our office.


  • Cancellation Policy

  • In order to serve the needs of all of our patients, we make every effort to be respectful of your schedule. If you cannot keep an appointment, we request that you give us a minimum of 24 hour notice. Patients who fail to arrive for their reserved appointments or who cancel without 24hr in advance will be charged a missed appointment fee of $65.00. Please note that this missed appointment fee is NOT covered by any insurance plan and is your responsibility to pay. We understand that situations may arise that may make it impossible to give 24hr notice, and each incident will be given individual consideration based on your appointment history.


  • ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

  • I acknowledge that I have received a copy of this dental practice’s Notice of Privacy Practices.


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