Acknowledgement of Receipt of Notice of Privacy Practices
I,
I understand that the HIPAA (Health Insurance Portability and Accountability Act of 1996), my health information will be used for treatment, payment, and healthcare operations. I also understand that I have certain rights in relation to my health information, and that I may contact this office or the United States Secretary of Health and Human Services.
I have reviewed the Notice of Privacy Practices which further explains HIPAA, and understand the information contained therein regarding the use and disclosure of my personal health information. I understand that Dental Dynamics, P.C. has the right to change its Notice of Privacy Practices (as changes or amendments are passed in federal or state legislation), and that I may contact the office with any questions or concerns regarding HIPAA. I may also obtain a current copy of Notice of Privacy Practices from Dental Dynamics, P.C.
I understand that I may request (in writing) that restrictions be placed on the use or disclosure of my private information when treatment, payment, or health questions are involved, and that Dental Dynamics, P.C. is not required to agree to my requested restrictions. If Dental Dynamics, P.C. does agree to my requested restrictions, then Dental Dynamics, P.C. is bound to abide by such restrictions.
I also understand that I may request that my health information be amended, and that a request to do so may be denied, but must be documented.
Name of Patient/Legal Guardian : I've Read the Above
Relationship to Patient :
Click to view Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY; THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the private practices that are described in this Notice while it is in effect. This Notice takes effect 04/14/03, and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations (TPO) . For example:
Treatment: We may use or disclose your health information to a physician or other healthcare provides providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for procedures and services we provide to you.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or for credentialing activities.
Your Authorization: In addition to our use of your health information for treatment, payment or health care operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice of Private Practices.
To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your locations, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based in a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practices to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
Other Disclosures: We may use and disclose your protected health information without your authorization to different individuals/organizations including law enforcement personnel, in reporting suspected abuse or neglect, and disaster relief agencies assisting in the notification of family members or others.
Patients Rights: The health and billing records we create and store are the property of Dental Dynamics, P.C. Your health information in general Belongs to you . You have the right to a) Receive, read, and ask questions about this Notice, b) Request certain restrictions be placed on the use and disclosure of your information,
Questions? If you have any questions or need more information, you may contact our privacy officer at 503-697-0884 . If you believe your privacy rights have been violated, please let us know, or deliver a written complaint to our privacy officer. Forms are available upon request. We will not retaliate against you for filling a complaint. You must also contact the United States secretary of Health and Human Services with questions or complaints.
Effective Date: April 14, 2003.
Financial Agreement
To Our Valued Patients,
Welcome to our family of patients. At Dental Dynamics we strive to achieve optimal oral health and care for you, our patients. Because we believe a smile opens doors, we partner with our patients to help you achieve the smile of your dreams.
As a courtesy to our patients, we will bill your insurance carrier for procedures completed. However, we do require that your insurance information be provided to us on or before your appointed time. If this information is not provided, we will collect for your visit in full at the time of service and you will be responsible for billing your insurance for reimbursement of your payment.
Also as a courtesy, we will provide a benefit estimate for each appointment. Our insurance estimate is based on information given to us by your insurance carrier, and is only an estimate. We collect as much information as we can so that our estimate can be as accurate as possible. In the end, it is the insurance company that has the final say on payment. Please understand that we strive to provide you with the best information we can obtain, and that after insurance payment is complete the remaining balance is billable to you. If you have questions regarding your benefits please call our office and we will be more than happy to inform you of your benefits plan and answer any questions you might have.
We ask that if you must cancel a scheduled appointment that you kindly give 48 hours notice. Dr. Saleh and the entire staff spend valuable preparation time arranging every detail for your visit. With respect to the staff that serves you and our other patients who depend on us, we appreciate timely cancellation notifications and alerts if you are running late. If sufficient notice is not received there is a customary fee of $30.00 for a missed hygiene appointment and a minimum fee of $50.00 for a missed treatment appointment. For extended treatment appointments, the minimum fee may be replaced with a fee of $150 per hour.
We collect all out of pocket expense in full on the date of service. If you have a financial concern, we are happy to share with you our payment plan options through either Wells Fargo Health Advantage or CareCredit. We can process your application in our office to help you achieve the best results. There are several no interest options available, as well as, low interest extended plans designed to fit your budget.
We look forward to getting to know you better through the years to come, and happily welcome you to our practice. Please acknowledge you understand the information listed above by signing below.
Sincerely,
Dr. Saleh and the Dental Dynamics Team
Name of Patient/Legal Guardian: I've Read the Above
Relationship to Patient :
Oral Screening Consent Form
We are continually looking for new technology that will enhance our ability to provide the optimum level of oral healthcare to our patients. We are concerned about oral cancer and look for it in every patient.
One American dies every hour from oral cancer. Late detection of oral cancer is the primary cause that both the incidence and mortality rates of oral cancer continue to increase. As with most cancers, age is the primary risk for oral cancer. Tobacco and alcohol use are other major predisposing risk factors but more than 25% of oral cancer victims have no such lifestyle risk factors. Oral cancer risk by patient profile is as follows:
Increased risk: patients ages 18-39
We have incorporated fluorescence visualization technology through Velscope into our oral screening standard of care. This enables us to identify suspicious areas at their earliest stages.
Velscope is similar to proven early detection procedures for other cancers such as mammography, Pap smear and PSA. This is a simple and painless examination that gives the best chance to find any oral abnormalities at the earliest possible stage. Early detection of pre-cancerous tissue can minimize or eliminate the potentially disfiguring effects of oral cancer and possibly save your life. This exam will be offered to you annually.
This enhanced examination is recognized by the American Dental Association code reviser committee as CDT-5 procedure code D0431; however, this exam might not be covered by your insurance. The fee for this enhanced examination is $39.
I authorize Dr. Mo Saleh to perform Velscope exam along with the standard oral cancer examination. I accept financial responsibility for this enhanced examination. Yes No
Name of Patient/Legal Guardian: I've Read the Above