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.

Anesthetics: Most procedures are performed with a local anesthetic (commonly referred to as Novocaine and Zyloccaine). In addition, sedative and pain medications can be used to help minimize anxiety and discomfort. In rare instances, allergic reactions may occur, so you are requested to inform our office staff of any known allergies yo may have. Some sedative or pain medication may cause drowsiness. Therefore, when these medications are used, you would need to make arrangements for transportation with another person to and from the office. Nitrous Oxide Sedation (laughing gas) is used as well.

Informed Consent and Authorization: I certify that I have read and understand this Informed Consent, which outlines the general treatment considerations as well as the potential problems and complication of dental treatment. I understand that potencial complications and problems may include, but are not limited to, those described in the treatment and discussed with me. I understand that during and following the treatment, and in the future, conditions may be become apparent that warrant additional or alternative treatment pertinent to the success of comprehensive treatment. Recognizing the potencialproblems and risks of dental treatment, authorization is given for dental treatment to be rendered by the dentist and office staff. I also approve any modification in design, materials, or care, if it is for my best interest. I consent that photographs and/or videos of the prodecures may be shown for teaching and eduactional purposes. This consent is in force indefinitely unless revoked by me in writing.