GENTLE DENTAL CARE OF ROCHESTER PC

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3 Patient Rules GENTLE DENTAL CARE OF ROCHESTER PC 1. All Forms and letters require 1 week to complete. This includes school forms, dental records, copy of x-rays, prior authorization request, referrals, and official letters. 2. Please bring in a current list of health conditions, previous and future surgeries, and all prescription and over the counter medications that you are taking. 3. Please bring in your current insurance card and photo ID with you to each appointment. If you have any changes on your insurance please come 15 minutes prior to your appointment time to complete necessary paperwork. 4. Please give us 24 hours notice during business hours if you will not be attending your scheduled appointment. We reserve the right to not reschedule any more appointments if you have missed appointments without a 24 hours cancellation. 5. Please show up for your appointment on time. This will ensure that all patients are seen in a timely manner. If you ever choose to arrive early for an appointment, we cannot guarantee you will be seen early. If you are going to be late for your appointment, please call the office to notify us. If you arrive late, you will be seen in the order that you arrived. If you are 15 minutes late to your appointment this will count as a missed appointment, and we will reschedule your appointment as soon as possible. 6. Our providers attempt to address any concerns that you may have at the time of your appointment. Please be patient when your provider is running behind. Also know that you will be given the same attention. 7. Please make that line when checking in or out, this will insure the privacy of all our patients. Have all co-payments ready when checking in. 8. When you re at the office or calling the office, we promise to speak to you with respect and courtesy. Therefore, we ask that you speak respectfully and with courtesy to our staff! Cursing and threatening tones will not be tolerated and will result in a permanent dismissal from the practice. Any personal conflicts should be addressed with the office manager by filling out the necessary forms prior to discussion. 1

4 9. While in waiting room, please keep cell phone conversations/game use at a reasonable volume, or please step outside if not possible. Once you are called for treatment cell phones should be put on silent or vibrate. No calls, video, or pictures are allowed during or in treatment, if discovered that this is violated you will be permanently dismissed from the office. If you are expecting an emergency call, please notify an assistant, and we can reschedule this appointment if needed. 10. When entering the lobby no food or drink will be allowed. If you or your parents must leave to eat, please notify a secretary before leaving the office. 11. No children under the age 15 years old can be left unattended in waiting room without being accompanied by an adult. If you come to your appointment without another adult to supervise your child/children, you will have to reschedule your appointment. 12. If you have an appointment and you need to step outside before you are called, for example a phone call, smoke, eat, etc., please notify the front desk before leaving, if failed to do so and you are called, this will result as a missed appointment. Please sign below to indicate that you have read and fully understand our policies. Date Patient Signature Thank you for your compliance with our patient rules. By following these guidelines we will be able to serve all of our patients efficiently and provide the best patient care. eprescriptions Pharmacy Name: Address: Phone: 2

5 Gentle Dental Care of Rochester PC Financial Policy All payment is due at time of service unless prior arrangements have been made. 1. Payment is required at the time services are rendered unless other arrangements have been made in advance. This includes applicable coinsurance and co-payments for participating insurance companies. Our insurance contracts do not allow us to waive co-payments. A $15.00 processing fee will be add to your balance if payment is not cover the day of service. 2. We accepts cash, money orders, VISA, MasterCard, Discover, American Express and Care Credit Payments. 3. All returned checks will be assessed a $30.00 service fee. 4. Patients with a balance 30 days or more overdue must make arrangements for payment prior to scheduling appointments. Accounts showing no progress for 60 days will be sent to a collections agency and you will be responsible for any added agency or legal charges. 5. You are responsible to inform us of updated and accurate insurance information for us to properly bill insurance on your behalf. Insurance information must be updated for each patient in the family as each patient has a separate account. 6. We bill participating insurance companies as a courtesy to you. You are required to pay your co-payments at the time of service. If we have not received payment from your insurance company within 45 days of the date of service, you may be expected to pay the balance in full. You are responsible to be sure all charges are paid, whether by you or by your insurance carrier. 7. Patients not covered by insurance are considered self pay and are required to make a full payment on their account at the time of service unless other arrangements have been made. 8. Broken appointments represent a cost to us, to you and to to other patients who could have been seen in the time set aside for you. Cancellations are requested 24 hours prior to the appointment (a Monday appointment would have to be changed by Friday) or there will be a thirty dollar ($30.00) charge. Missed appointments without at least twenty four (24) hours notice to our staff may result in discharge from the practice. Please sign below to indicate that you have read and fully understand our policy. Date Full Name of patient or Responsable Social Security Signature

6 GENTLE DENTAL CARE OF ROCHESTER PC AUTHORIZATION OF USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION. I was given the opportunity to review the Gentle Dental Care of Rochester, PC HIPAA Notice of Privacy Practices. I authorize Gentle Dental Care of Rochester, PC to communicate information to me regarding appointments, medications, approvals, referrals, and treatment plan by leaving a message on the answering machine/voic at the following telephone number(s) and/or (s): Home #: Cell phone #: Signature Date I authorize Gentle Dental Care of Rochester, PC to disclose the following information: Medications Appointments Approvals Treatment Plan Only the following information To the following individual(s): Name Relationship Telephone Name Relationship Telephone Name Relationship Telephone This authorization is effective through / / unless revoked or terminated by the patient or patients representative. You may revoke or terminate this authorization by submitting a written revocation to our office. The privacy of this information may not be protected under the federal privacy regulations if disclosed by individuals listed above. Print Name DOB / / Signature Date / / Signature of Representative/Guardian Relationship with patient

7 GENTLE DENTAL CARE OF ROCHESTER PC NOTICE OF PRIVACY PRACTICES EFFECTIVE DATE: 09/01/2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. UNDERSTANDING YOUR HEALTH RECORD/INFORMATION Each time you visit a hospital, physician, dentist, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information often referred to as your health or medical record, serves as a basis for planning your care and treatment and serves as a means of communication among the many health professionals who contribute to your care. Understanding what is in your record and how your health information is used helps you to ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and helps you make more informed decisions when authorizing disclosure to others. YOUR HEALTH INFORMATION RIGHTS Unless otherwise required by law, your health record is the physical property of the healthcare practitioner or facility that compiled it. However, you have certain rights with respect to the information. You have the right to: 1. Receive a copy of this Notice of Privacy Practices from us upon enrollment or upon request. 2. Request restrictions on our uses and disclosures of your protected health information for treatment, payment and health care operations. This includes your right to request that we not disclose your health information to a health plan for payment or health care operations if you have paid in full and out of pocket for the services provided. We reserve the right not to agree to a given requested restriction. 3. Request to receive communications of protected health information in confidence. 4. Inspect and obtain a copy of the protected health information contained in your medical and billing records and in any other Practice records used by us to make decisions about you. If we maintain or use electronic health records, you will also have the right to obtain a copy or forward a copy of your electronic health record to a third party. A reasonable copying/labor charge may apply. 5. Request an amendment to your protected health information. However, we may deny your request for an amendment, if we determine that the protected health information or record that is the subject of the request: was not created by us, unless you provide a reasonable basis to believe that the originator of the protected health information is no longer available to act on the requested amendment; is not part of your medical or billing records; is not available for inspection as set forth above; or is accurate and complete. In any event, any agreed upon amendment will be included as an addition to, and not a replacement of, already existing records. 6. Receive an accounting of disclosures of protected health information made by us to individuals or entities other than to you, except for disclosures: to carry out treatment, payment and health care operations as provided above; to persons involved in your care or for other notification purposes as provided by law; to correctional institutions or law enforcement officials as provided by law; for national security or intelligence purposes; that occurred prior to the date of compliance with privacy standards (April 14, 2003); incidental to other permissible uses or disclosures; that are part of a limited data set (does not contain protected health information that directly identifies individuals); made to patient or their personal representatives; for which a written authorization form from the patient has been received 7. Revoke your authorization to use or disclose health information except to the extent that we have already been taken action in reliance on your authorization, or if the authorization was obtained as a condition of obtaining insurance coverage and other applicable law provides the insurer that obtained the authorization with the right to contest a claim under the policy. 8. Receive notification if affected by a breach of unsecured PHI Copyright , HIPAATraining.com

8 HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED This organization may use and/or disclose your medical information for the following purposes: Treatment: We may use and disclose protected health information in the provision, coordination, or management of your health care, including consultations between health care providers regarding your care and referrals for health care from one health care provider to another. Payment: We may use and disclose protected health information to obtain reimbursement for the health care provided to you, including determinations of eligibility and coverage and other utilization review activities. Regular Healthcare Operations: We may use and disclose protected health information to support functions of our practice related to treatment and payment, such as quality assurance activities, case management, receiving and responding to patient complaints, physician reviews, compliance programs, audits, business planning, development, management and administrative activities. Appointment Reminders: We may use and disclose protected health information to contact you to provide appointment reminders. Treatment Alternatives: We may use and disclose protected health information to tell you about or recommend possible treatment alternatives or other health related benefits and services that may be of interest to you Health-Related Benefits and Services: We may use and disclose protected health information to tell you about health-related benefits, services, or medical education classes that may be of interest to you. Individuals Involved in Your Care or Payment for Your Care: Unless you object, we may disclose your protected health information to your family or friends or any other individual identified by you when they are involved in your care or the payment for your care. We will only disclose the protected health information directly relevant to their involvement in your care or payment. We may also disclose your protected health information to notify a person responsible for your care (or to identify such person) of your location, general condition or death. Business Associates: There may be some services provided in our organization through contracts with Business Associates. Examples include physician services in the emergency department and radiology, certain laboratory tests, and a copy service we use when making copies of your health record. When these services are contracted, we may disclose some or all of your health information to our Business Associate so that they can perform the job we have asked them to do. To protect your health information, however, we require the Business Associate to appropriately safeguard your information. Organ and Tissue Donation: If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation. Worker's Compensation: We may release protected health information about you for programs that provide benefits for work related injuries or illness. Communicable Diseases: We may disclose protected health information to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. Health Oversight Activities: We may disclose protected health information to federal or state agencies that oversee our activities. Law Enforcement: We may disclose protected health information as required by law or in response to a valid judge ordered subpoena. For example in cases of victims of abuse or domestic violence; to identify or locate a suspect, fugitive, material witness, or missing person; related to judicial or administrative proceedings; or related to other law enforcement purposes. Military and Veterans: If you are a member of the armed forces, we may release protected health information about you as required by military command authorities. Lawsuits and Disputes: We may disclose protected health information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process. Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release protected health information about you to the correctional institution or law enforcement official. An inmate does not have the right to the Notice of Privacy Practices. Abuse or Neglect: We may disclose protected health information to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law. Fund raising: Unless you notify us you object, we may contact you as part of a fund raising effort for our practice. You may opt out of receiving fund raising materials by notifying the practice s privacy officer at any time at the telephone number or the address at the end of this document. This will also be documented and described in any fund raising material you receive. Coroners, Medical Examiners, and Funeral Directors: We may release protected health information to a coroner or medical examiner. This may be necessary to identify a deceased person or determine the cause of death. We may also release protected health information about patients to funeral directors as necessary to carry out their duties. Public Health Risks: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose such as controlling disease, injury or disability. Serious Threats: As permitted by applicable law and standards of ethical conduct, we may use and disclose protected health information if we, in good faith, believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. Food and Drug Administration (FDA): As required by law, we may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement. Research (inpatient): We may disclose information to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved their research. Copyright , HIPAATraining.com

9 OUR RESPONSIBILITIES We are required to maintain the privacy of your health information. In addition, we are required to provide you with a notice of our legal duties and privacy practices with respect to information we collect and maintain about you. We must abide by the terms of this notice. We reserve the right to change our practices and to make the new provisions effective for all the protected health information we maintain. If our information practices change, a revised notice will be mailed to the address you have supplied upon request. If we maintain a Web site that provides information about our patient/customer services or benefits, the new notice will be posted on that Web site. Your health information will not be used or disclosed without your written authorization, except as described in this notice. The following uses and disclosures will be made only with explicit authorization from you: (i) uses and disclosures of your health information for marketing purposes, including subsidized treatment communications; (ii) disclosures that constitute a sale of your health information; and (iii) other uses and disclosures not described in the notice. Except as noted above, you may revoke your authorization in writing at any time. FOR MORE INFORMATION OR TO REPORT A PROBLEM If you have questions about this notice or would like additional information, you may contact our Privacy Officer, Cathy Botana, at the telephone or address below. If you believe that your privacy rights have been violated, you have the right to file a complaint with the Privacy Officer at GENTLE DENTAL CARE OF ROCHESTER or with the Secretary of the Department of Health and Human Services. The complaint must be in writing, describe the acts or omissions that you believe violate your privacy rights, and be filed within 180 days of when you knew or should have known that the act or omission occurred. We will take no retaliatory action against you if you make such complaints. The contact information for both is included below. U.S. Department of Health and Human Services Office of the Secretary 200 Independence Avenue, S.W. Washington, D.C Tel: (202) Toll Free: GENTLE DENTAL CARE OF ROCHESTER PC Cathy Botana Privacy Officer 295 Monroe Avenue, Rochester NY Tel: Fax: admin@rochestergentledentalpc.com NOTICE OF PRIVACY PRACTICES AVAILABILITY This notice will be prominently posted in the office where registration occurs. You will be provided a hard copy; at the time we first deliver services to you. Thereafter, you may obtain a copy upon request, and the notice will be maintained on the organization s Web site for downloading. Copyright , HIPAATraining.com