Your Health Information May Be Used...
To Provide Treatment
We will use your HEALTH INFORMATION within our office to provide you with the best dental care possible. This may include administrative and clinical office procedures designed to optimize scheduling and coordination of care between hygienist, dental assistant, dentist, and business office staff. In addition, we may share your health information with physicians, referring dentists, clinical and dental labs, pharmacies or other health care personnel providing you treatment.
To Obtain Payment
We may include your health information with an invoice used to collect payment for treatment yu receive in our office. We may do this with insurance forms filed for you in the mail or sent electronically. We will be sure to only work with the companies with a similar commitment to the security of our health information.
To Conduct Health Care Operations
Your health information may be used during performance evaluations of our staff. Some of our best teaching opportunities use clinical experienced by patients receiving care at our office. As a result, health information may be including in training programs. It is also possible that health information will be disclosed during audits by insurance companies or government appointed as part of their quality assurance and compliance reviews. Your health information may be reviewed during the routine processes of certification, licensing or credentialing activities.
In Patient Reminders
Because we believe regular care is very important to your oral and general health, we will remind you of a scheduled appointment or that it is time for you to contact us and make an appointment. Additionally, we may contact you to follow up on your care and inform you of treatment options or services that may be of interest to you or your family. These communications are an important part of our philosophy of patterning with our patients to be sure they receive the best preventive and restorative care modern dentistry can provide. They may include postcards, folding postcards, letters, telephone reminders, email or texting.
Public Health and National Security
We may be required to disclose to Federal Officials or military authorities health information necessary to complete an investigation related to public health or national security. Health information could be important when the goverment believes that the public safety could benefit when the information could lead to the control or prevention of an epidemic or the understanding of new side effects of a drug treatment or a medical device.
Family, Friends and Care Givers
We may share your health information with those you tell us will be helping you with your home hygiene, treatment, medication, or payment. We will be sure to ask your permission first. If there is an emergency , where you are unable to tell us what you want we will use our very best judment when sharing your health information omly when it will be important to those participating in providing your care.
Consent for Services
- Patient who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges wil be paid by an insurance company.
- A late charge may apply on unpaid balances exceeding 30 days.
- I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient's examination.
- I grant permission to you or your assignee, to telephone mr at home or at my work to discuss matters related to this form.
- A service charge of 1 1/2% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arragements are satisfied.