HIPPA Notice of Privacy Act

Office Policy and Notice of HIPAA Privacy Practice

Thank you for choosing our practice for your dental health needs. Our goal is to provide quality care to all our patients with affordable fees. We are dedicated to making healthcare less stressful and more valuable by clarifying financial responsibilities in advance.

It is our office policy to bill your insurance carrier as a courtesy to you. Therefore it is your responsibility to make sure we have current insurance information for you and your family. Ultimately any remaining balance not covered by your insurance is your responsibility. Payment may be made by CHECK, CASH,VISA, MASTERCARD, or DISCOVER. If unable to pay in full we offer CITICARD and SPRINGSTONE financing. There is a returned check fee of $25.00 for all checks returned to us by the bank for insufficient funds.

Our office will be happy to make arrangements in advance of service for extensive dental treatment. Our office however, will charge for a broken or no show appointment with less than 48 hours notice and will require a deposit on the rescheduled appoiThis notice of Privacy Practice describes how we as health care providers may use and disclose your protected information to carry out treatment, payment and health care operations and for other purposes that are permitted or required by law.

Protected Health Information (PHI) is information about you, including demographic information. That may identify you and that relates to your past, present and future physical or mental health or condition and related to health care services.

The Department of Health and Human Services has established a “Privacy Policy” to help insure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients’ consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations.

As our patient, we want you to know that we respect the privacy of your personal medical records and will do all we can to assure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment or health care operations, in order to provide health care that is in your best interest.

We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients), and may have to disclose personal health information for purposes of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent.

You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal

If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent. If you have any objections to this form, please ask to speak with our HIPPA Compliance Officer.