Acknowledgement of Privacy Practices

Transcription

1 To view our Notice of Privacy Practices from the link below. 31TUhttp:// Acknowledgement of Privacy Practices I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: *Conduct, plan and direct my treatment and follow-up care among the multiple healthcare providers who may be involved in that treatment directly or indirectly. *Obtain payment from designated third-party payers. *Conduct normal health care operations such as quality assessments or evaluations, and physician certifications. I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information (available in office in print form or on the office website WorldPediatricDental.com). I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address(s) below to obtain a current copy of the Notices of Privacy Practices. I understand that I may request in writing that this organization restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand the organization is not required to agree to my requested restrictions, but if the organization does agree, then it is bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that the organization has taken action relying on this consent. Patient s Name Date of Birth (MM/DD/YYYY) Signed (Patient or Legal Representative for Patient) Date Legal Representatives Relationship to Patient Hardy Oak Blvd Suite 305 San Antonio, TX p(210) f(210)

2 Authorization Agreement World Pediatric Dental offers patients the ability to communicate with healthcare providers via electronic mail ( ) for non-urgent matters. Both you, the patient, and your provider have to agree to this arrangement. No information is ever sent electronically without permission given by you or your legally authorized representative. Appropriate uses for may be used to request information and ask non- urgent questions. It should not be used in emergencies. If you are experiencing a sudden or severe change in your health, or otherwise need an immediate response, please contact your healthcare provider s office by telephone, call 911, or go to an emergency room. may be used to send protected personal health information for: Prescriptions/refills, General medical advice after an initial visit, Lab test results, Patient educational material Once we have received your permission, we will be able to send s to the address you provide. The risk associated with this e- mail mechanism is if others have access to your , they will have the ability to click on the link and will be able to view the information. If you have an address and would like to take advantage of this service, please discuss your wishes with your healthcare provider (e.g., doctor) first. Some providers do not communicate with their patients electronically. Others may ask an associate such as a nurse or billing person to contact you, based on your e- mail request. World Pediatric Dental may forward s as appropriate for diagnosis, treatment, and other related reasons. As such, World Pediatric Dental staff, other than your provider, may have access to s that you send. Such access is only to make available healthcare services to you. Otherwise, World Pediatric Dental will not forward s to anyo ne else without your prior written consent, except as authorized or required by law. Keeping records of communications communications will be documented as an electronic note maintained in a computer system filed in your medical record. Sending Please include your full name and account number on every message that you send to our office. This information is required so we can establish that the person requesting information is in fact the person the sender claims to be. Without this, we will not be able to address your questions. The subject line should include the purpose of the , for example: Appointment Information. If a message is ever returned because of a bad address please make sure that you entered the complete address as it was given to you. If you are sure that you entered the address the provider gave to you, please call the provider s office and make sure you have the correct e- mail address and that the computer system is functioning properly. If we not answer your in 2-3 days contact the office by telephone. Privacy and security of Do not use to send or request sensitive information. This includes personal information you do not want other people to know about. Additionally, you should be aware of and understand that if you use provided by your employer, any sent on your employer s system may be viewed by your employer. World Pediatric Dental cannot and does not guarantee the privacy or security of any messages being sent over the Internet. There is the potential that sent over the Internet can be intercepted and read by others. If this is of concern to you, you should not communicate with your healthcare provider through e- mail. Authorization to use I have been informed of and understand the risks and procedures involved with using . I agree to the terms listed on this form and hereby voluntarily request, consent to, and authorize the use of as one form of communication with my physician, and his/her associates, technicians and other health care providers. Patient Signature: Patient Representative Signature: Relationship to Patient: Date: This document along with World Pediatric Dental's Notice of Privacy Practices constitutes a notice of privacy practices for use as required by the TSBDE

3 INFORMED CONSENT FOR PEDIATRIC DENTAL TREATMENT OF: Patient Name It is necessary for us as health professionals to obtain your consent for your child s planned dental treatment or oral surgery. Please read this form carefully and ask about anything that you do not understand. 1. I hereby authorize Dr. Oshmi Dutta and/or his Associate and their hygienists/assistants to perform upon my child the following dental treatment or oral surgery procedures, including the use of any necessary or advisable local anesthesia, analgesia, or radiographs. In general terms, the dental procedures will include: a. Teeth cleaning, fluoride application, and any necessary X-rays b. Photograph, film, videotape, record and/or interview (may be used either internally or externally) c. Applying plastic sealants to the grooves of teeth d. Repairing diseased or broken teeth with fillings or crowns e. Treating infected teeth and/or gums f. Removal of one or more teeth **I understand that on some occasions treatment is subject to change once in the dental treatment chair. I authorize any necessary changes to be made by Dr.Dutta and/ or his Associates to do what is in the best interest of my child. 2. I have had explained to me by Dr. Oshmi Dutta and/or his Associate, and have had sufficient opportunity to discuss the patient s dental condition/problem(s), the planned procedures and treatment, and the benefits to be reasonably expected from this treatment plan, compared with alternative approaches and/or no treatment. 3. Although their occurrence is extremely remote, some risks are known to be associated with dental procedures. The usual and most frequent risks or complications occurring from the planned treatment and procedures also have been explained to me. These risks include but are not limited to, the possibility of pain or discomfort during the treatment, swelling, infection, bleeding, injury to adjacent teeth and surrounding tissue, development of a temporomandibular joint disorder, temporary or permanent numbness, and allergic reactions. Occasionally, a child may also chew/irritate his or her own cheek, lip, or tongue while numb. It is the responsibility of the parent to closely monitor children who are numb to decrease the risk of such complication. 4. I understand that treatment for children includes efforts to guide their behavior by helping them to understand the treatment in terms appropriate for their age. Behavior will be guided using praise, explanation and demonstration of procedures and instruments, using variable voice tone and loudness. 5. I understand that should the patient become uncooperative during dental procedures with movement of the head, arms and/or legs, dental treatment cannot be safely provided. During such disruptive behavior, it may be necessary for the assistant(s) to hold the patient s hands, stabilize the head and/or control leg movements. 6. I further understand that should the patient become uncooperative during dental procedures with excessive body movements, the patient may need to be wrapped in an immobilization wrap or papoose board to prevent injury and enable Dr.Dutta and/or his Associate to safely provide the necessary treatment. Should the use of the wrap become necessary, you will be asked to sign the following statement: Hardy Oak Blvd Suite 305 San Antonio, TX p(210) f(210)

4 I consent to the use of the stabilization wrap. Signature: Date:. In general terms, the behavior management techniques during treatment will include: a. Tell, Show, Do b. Distraction c. Positive reinforcement d. Use of voice control to gain the attention of a disruptive child e. Use of physical restraint to safely accomplish necessary dental procedures. This may include hand and/or head holding, as well as an immobilization wrap (papoose). The above behavior management techniques have been explained to me both verbally and in writing. I have had a chance to ask questions. I understand the what, when, how, and why of their use, and the risks/benefits/available alternatives. 5. For the purpose of advancing medical-dental education, I give permission for the use of clinical photographs of the patient for diagnostic, scientific, educational or research purposes. 6. I understand that I may revoke this consent to treatment at any time and that no further action based on this consent will be initiated except to the extent that treatment and procedures have already been performed or initiated. 7. I confirm that I have read (or it was read to me) and understand the information on the front and back of this form, and that all blanks were filled in, and all inapplicable paragraphs, if any, were stricken before I signed below. The proposed treatment has been explained to me, as have any alternative methods of treatment, and the advantages and disadvantages of each. I am advised that although good results are expected, the possibility and nature of complications cannot always be accurately anticipated. Therefore, there can be no guarantee as to the result of the treatment. I understand the treatment proposed and give permission to Dr.Dutta and/or his Associate(s) to complete any treatment needed and make any changes as needed. I refuse to give my consent of the proposed treatment and fully understand the consequences of not having the treatment done for my child. Parent/Guardian Date Witness Oshmi Dutta DDS, MS Date Hardy Oak Blvd Suite 305 San Antonio, TX p(210) f(210)

5 Dental Office Policy on Dental Insurance Patients with Dental Insurance: As a courtesy to you, we will gladly submit to your insurance. We are able to bill to all traditional and indemnity insurance plans. We do accept some DMO or DPO plans (Dental Maintenance or Dental Provider Organizations). Under these plans, there is no coverage when treatment is rendered by a non-participating dentist. In most cases, DMOs only approve specialty care for children under age 6. We must have a referral from your Primary Cared Dentist (PCD) for care under Pediatric Specialist. Please check your type of plan carefully. For more specific information about in and out-of-network benefit amounts, please call your insurance company. Authorization to Release Info and Assignment of Benefits: I certify that I,(or my dependent) have (has) dental insurance coverage and assign directly to the treating dentist all insurance benefits, if any, otherwise payable to me for services rendered. I hereby authorize the doctor and/or her staff to release all necessary personal information to my insurance company in order to secure the payment of benefits. Payments: We accept cash, check, and most credit cards. Payment of your estimated portion is due at the time services are rendered, such as your annual deductible and/or percentage of the treatment not covered by insurance. As a courtesy, we will gladly contact your insurance in order to provide an estimate of your patient portion. However, despite this, we cannot guarantee the payment of insurance benefits nor can we provide 100% accuracy of this estimated amount since many factors are involved that determine the actual payment of benefits once submitted and processed by your insurance. Keep in mind that many insurance companies base their quoted percentage of coverage (i.e. 100%, 80%, 50%, ect.) on their own fee schedule, and not our office's actual fees, which may result in a balance due higher than expected. Should an outstanding balance due result after your insurance company processes your claim, you will then be contacted to inform you of the underpayment. Payment can be made over the phone, on our website, or by mail. If a credit balance should result after insurance processes your claim, a refund will reflect on your account. You can request this refund to be payable to you by informing our finance officer. Unpaid Insurance Claims: All dental services rendered, whether or not covered by insurance, are ultimately the financial responsibility of the account holder. We will give your insurance company 60 days to remit payment. If there is still no payment after this time, in order to keep your account current, you will be financially responsible for 100% of the outstanding insurance claim. You will be contacted, and payment can be made over the phone, on our website, or by mail. It is the responsibility of the account holder to follow up with their own insurance company regarding the non- payment of a claim. Should our office eventually receive a payment from your insurance after it has been paid by you, a prompt refund will be issued. Past-Due Accounts: If payment is not received, then your account is considered past due. If the balance is still unpaid after 90 days, the account will be turned over for further collection action. If an account is turned over to our collection agency and/or our attorney for collection, the account holder will be responsible for ALL attorney and/or collection fees that this o ce incurs while attempting to collect on the unpaid balance. These collection fees will be added to the outstanding portion of the account, and will also become the financial responsibility of the account holder. By signing below I verify that I completely understand, agree, and accept the policies outlined above. I further acknowledge that I am responsible for all dental services rendered me and my dependents (if applicable). Patient Name: Date: Parent/Guardian Signature: Date: