NOTICE OF PRIVACY PRACTICES. This notice describes how health information about you may be used and Disclosed and how you can get access to this information. Please review it carefully. The privacy of your health information is important to us.
We are required by applicable federal and state law to maintain the privacy of your protected health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 4/11/2013 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 provide the new Notice at our practice location, and we will distribute it upon request.
You may request a copy of our Notice at any time. You may receive a paper copy of this notice upon request, even if you have agreed to receive this notice electronically on our Web site or by electronic mail (e-mail).
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.
In addition to our use of your health information for the following purposes, 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.
We use and disclose health information about you without authorization for the following purposes.
Treatment: We may use or disclose your health information for your treatment. For example, we may disclose your health information to a physician or other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you. For example, we may send claims to your dental health plan containing certain health information.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. For example, 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 credentialing activities.
Disaster Relief: We may use or disclose your health information to assist in disaster relief efforts.
Required by Law: We may use or disclose your health information when we are required to do so by law.
Public Health and Public Benefit: We may use or disclose your health information to report abuse, neglect, or domestic violence; to report disease, injury, and vital statistics; to report certain information to the Food and Drug Administration (FDA); to alert someone who may be at risk of contracting or spreading a disease; for health oversight activities; for certain judicial and administrative proceedings; for certain law enforcement purposes; to avert a serious threat to health or safety; and to comply with workers’ compensation or similar programs.
Decedents: We may disclose health information about a decedent as authorized or required by law.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody the protected health information of an inmate or patient under certain circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, email messages, text messages postcards, or letters) at your home or office.
Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.
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 your personal representative, but only if you agree that we may do so.
We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, 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 absence or incapacity or in emergency circumstances, we will disclose health information based on 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 practice 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
You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice.
You have the right to receive a list of instances in which our business associates or we disclosed your health information for purposes other than treatment, payment, healthcare operations, and certain other activities, for the last six years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
You have the right to request that we place additional restrictions on our use or disclosure of your health information. In most cases, we are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in certain circumstances where disclosure is required or permitted, such as an emergency, for public health activities, or when disclosure is required by law). We must comply with a request to restrict the disclosure of protected health information to a health plan for purposes of carrying out payment or healthcare operations (as defined by HIPAA) if the protected health information pertains solely to a healthcare item or service for which we have been paid out of pocket in full.
You will receive notifications of breaches of your unsecured protected health information as required by law.
You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide a satisfactory explanation of how payments will be handled under the alternative means or location you request.
You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may not be able to comply with your request under certain circumstances.
You have the right to file a formal, written complaint with us at the address below, or with the Department of Health & Human Services, Office of Civil Rights, in the event you feel your privacy rights have been violated.
For more information about HIPAA or to file a complaint:
The U.S. Dept of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington DC 20201
Thank you for choosing Summit DentalCare for your dental needs. We are committed to providing you with excellent care and convenient financial options. We realize you may be requiring some dental care and it is easy to forget that a doctor’s office is also a small business. In the interest of both good medicine and good business, we believe it is best to establish a policy to avoid any misunderstandings later. As a result, we have developed this policy.
Payment for service is due at the time services are provided unless other payment arrangements have been approved in advance. We accept cash, check, bank debit, Visa, MasterCard, Discover and American Express. You might also be interested in taking advantage of one of our financing options we have available through third-party financing. By utilizing this wonderful finance option, your entire family will enjoy the excellent treatment we provide with minimum easy-to-budget monthly payments. They offer a variety of INTEREST-FREE financing including plans with 3, 6, 12 months but have an option of 18 or 24 months no interest depending on the amount financed. Patients will not be denied services based on inability to pay and that discounts are available based on family size and income.
The responsible party agrees to pay all attorney fees and court costs associated with collecting payment for services rendered. Collection fees of approximately 50% are added to the account when it is turned over to the agency.
The policy of this office is to charge 25% monthly interest which is applied to all accounts over 30 days past due. We will charge $40.00 for returned checks.
We will be happy to process your insurance claim form electronically as a courtesy to you. If you have insurance, please be prepared to pay your portion of the total treatment fee on the day of service. Please understand that insurance policies vary greatly; therefore, we can only estimate your coverage in good faith, but cannot guarantee coverage due to the complexities of insurance contracts. As a service to our patients, we will bill insurance carriers on your behalf for the services performed. We will allow them 45 days to render payment. After 60 days, you are responsible for the remaining balance in full. Remember, your dental insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract. If you have any questions about insurance information or are uncertain regarding coverage, please do not hesitate to ask us. We are here to help you.
I authorize the dentist or his designees to release financially identifiable information and treatment descriptions and information either electronically, by facsimile or paper form to my insurance carrier or any related entities that require such information.
Missed or Cancelled Appointments:
Once an appointment has been made, please remember that this time has been reserved specifically for you. We reserve the right to charge a fee ($25.00) for all canceled or missed appointments without 48-hour notice.
Timeliness and Communication:
We are committed to seeing you on-time and request you are on-time for your visits as well. This way, we can ensure all our patients are seen when promised. As it relates to communications, we request you give us permission to tell you exactly what is happening with your dental condition and explain how to treat that condition(s) best.