NOTICE OF PRIVACY PRACTICES

Similar documents
FINANCIAL POLICY 1. Patients with Dental Insurance 2. Self Pay Patients 3. Billing

Notice Of Privacy Practices

First&Appointment& Medical&History& Recall&Appointments& Cancelled/Failed&Appointments& Payments& Insurance&

Appointment Policy. Insurance Policy

Singh Family Dental Dr. P. Singh, PLLC

New Patient Information and Forms

St. Michael Dental Posthumus & Biorn, Inc.

Notice of Privacy Practices

Our philosophy of care governs everything we do for you. It consists of the following key elements:

SMILE ANALYSIS. How s Your Smile? YES NO (Look in the mirror as you answer these questions)

GETTING TO KNOW YOU. 1. How important is it for you to keep your teeth healthy for a lifetime?

Sparta Dental Center Office Policy Statement

Regulatory Compliance

Notice of Privacy Practices

LITTLE ROCK FAMILY DENTAL CARE

NOTICE OF PRIVACY PRACTICES

Fairview Dental. Patient Information: Patient First Name: MI: Last: Preferred Name: Date of birth: SS#: Address: City: Zip: Home Ph: Cell: :

Welcome to a Brighter Morgantown!

Consent for Services and Financial Policy

Patient Information Patient Info. Update

Picasso Aesthetic and Cosmetic Dental Spa NOTICE OF PRIVACY PRACTICES

Home Phone Work Phone Cell Phone In the event of an emergency, who should we contact? Name Relationship Emergency Contact Phone

Patient Information. Last First MI (Preferred Name) Male Female Married Single Child. City State Zip Code Emergency Contact/Relation Phone

NEW PATIENT INFORMATION FORM

Germantown Smiles,PC Germantown Road Suite 225 Germantown, Maryland

Please check if patient is a minor/child. First Name: Last Name: Middle Initial: Preferred name: Address: City: State: Zip: Home: Work: Cell:

York Smile Care. First: Middle: Last: Jr/Sr: Street: City: State Zip: Home Phone: Work Phone: Cell Phone: Patient's Employer:

Connecticut Asthma & Allergy Center LLC Registration Form

425 North Wendover Road Charlotte, NC Birthdate: Social Security #: Male Female

Medical History. Authorization to Treat. Financial Policy. Notice of Privacy Practice

Patient Information. Name Soc. Sec. # Last Name First Name Middle Initial. Address. City State Zip. Home Phone Cell Phone

LANCE OSBORNE DENTISTRY LANCE OSBORNE, DDS SCOTT ZIMMEREBNER, DDS 245 Van Asche Loop Fayetteville, Arkansas

First Name: Last Name: Initial:

OFFICE FINANCIAL POLICY

HAROLD GOODMAN, D.O SECOND AVENUE SUITE 405B SILVER SPRING, MD Patient Information

CHILDREN S DENTISTRY OF RANCHO CUCAMONGA Welcome to our practice!

Conte See Oue Exei^ing

Name Relationship Did you hear about us in any other way?

PATIENT REGISTRATION AND MEDICAL HISTORY (PLEASE PRINT IN BLACK INK ONLY)

NOTICE OF PRIVACY PRACTICES

Doc Bresler s Cavity Busters - New Patient History Form

1984 Isaac Newton Sq. W. #100 Reston, VA Patient Information

First Name: Middle Name: Last Name: Preferred Name: Address: City: State: Zip: Mother s First & Last Name: Mother s Home Phone: Mother s Work Phone:

Need help with frequent crisis, housing, transportation?

Acknowledgement of Receipt of Notice of Privacy Practices

SUMMARY OF NOTICE OF PRIVACY PRACTICES

New Beginning Pediatric Rehab ~ Maryland s Trusted Rehabilitation Practice ~ (410) Office (877) Fax

Important Facts Regarding Our Practice

EFFECTIVE DATE OF THIS NOTICE: 8/5/09

Is this your child s first visit to the dentist? Yes No If no, date of: last exam dental x-rays fluoride treatment

PATIENT INFORMATION. Name of child Date of Birth Age Sex Last First Middle Preferred Name (Nickname) HomeAddress Street City State Zip

All Dental 76 Otis Street Westborough, MA 01581

SUMMARY OF NOTICE OF PRIVACY PRACTICES

PATIENT REGISTRATION & HEALTH HISTORY FORM

Thomas Yoon Dental Patient Information. Health Information

Kathy A Curtis DDS, PLLC Downtown Dentistry

Our portals are encrypted and password-protected, too, so health data remains secure.

Agile Mind Counseling 506 Maple Street A Wellness Approach Athens, Tn

Child Health/Dental History Form

Your Physical health is: Good Fair Poor Are you currently under the care of a physician? Yes No Please explain:

Permission to Discuss Medical Information HIPPA PATIENT ACKNOWLEDMENT. Patient Name:

New Patient Information Form

Center for Emotional Wellness & Healing, LLC 100 Heritage Valley Rd, Ste. 1, Sewell, NJ 08080

X X Capistrano Children s Dentistry Child Patient Information

Welcome To. Concord Pediatric Dentistry. First Middle Last. Street City State Zip. Dental Insurance Information

PATIENT INFORMATION FORM

Regulatory Compliance

HIPAA Notice of Privacy Practices

Consent for Purposes of Treatment, Payment and Healthcare Operations

PATIENT INFORMATION PARENT / GUARDIAN INFORMATION

Just for Kids Pediatric Dentistry, Ltd. Patient Information

Northwest Ohio Orthopedics and Sports Medicine, Inc CR 236 Findlay, Ohio

Patient Information: Date: Name: Married Single Minor Male Female Last First Middle Preferred. Birth date: S.S.N.# ID/DL#: Month /Day /Year

or provide a seperate list

Notice of Privacy Policies

DAHL DENTISTRY. 46 PARK PLACE, SUITE A BRANFORD, CT (203) (203) FAX

MANUAL OF UNIVERSITY POLICIES PROCEDURES AND GUIDELINES. Applies to: faculty staff students student employees visitors contractors

Child s Name: Last First Middle Preferred Name. Address: Street Apt.# City State Zip. Mother Stepmother Guardian. Name: Employer: Social Security #:

Patient ad t Information. Insurance Information. Dental History

Trinity Family Physicians

FOOTHILLS SPORTS MEDICINE PHYSICAL THERAPY. PATIENT REGISTRATION FORM Please Print

PRIVACY NOTICE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

M F Last Name First Name Middle Initial Gender. Home Phone: Work Phone: Cell Phone: Physical Address: Mailing Address (if different):

Spink Dentistry New Patient Questionnaire: Patient Name: Cell: General check-up Toothache Veneers. Cavity or Filling Implant Crown or Bridge

FOOTHILLS SPORTS MEDICINE AND REHABILITATION. PATIENT REGISTRATION FORM Please Print

My Scottsdale Dentist. Patient Name: Date: Address: Birth Date: Gender (circle): M / F Family Status (circle):

CREEKSIDE DENTAL REGISTRATION FORM. Please Print PATIENT INFORMATION. Patient s Last Name: First: Middle:

Would you like to receive s with special offers from Carolina Vein Center? yes no

Cardiology Consultants of Atlanta, P.C N. Decatur Rd. Suite 395, Decatur GA, (404) phone (678) fax

Jody Finazzo,dds, ms

Cosmetic Dental Concerns

UNITED WORKERS HEALTH FUND 50 CHARLES LINDBERGH BLVD. SUITE 207 UNIONDALE, NY 11553

FOOTHILLS SPORTS MEDICINE AND REHABILITATION. PATIENT REGISTRATION FORM Please Print

ADKINS CHIROPRACTIC LIFE CENTER 157 KEVELING DRIVE SALINE, MICHIGAN Notice of Patient Privacy Policy

PATIENT INFORMATION. Name: Last First Middle Initial Nickname D.O.B. Social Security#: Marital Status: Sex: Male or Female Address:

Betty Kratzenberg, MS, LMFT INITIAL CLIENT INFORMATION

Secondary Insurance Co. Name & Address: Subscriber s Name: Subscriber Soc. Sec. No. Group number:

Patient Information DOB. Female Male Single Married Divorced Widowed. Address City State Zip Code. SSN Home Phone Cell Address

Patient registration. MyIdealDental.com. Primary insurance information. Secondary insurance information

HIPAA PRIVACY NOTICE CONSENT FORM HIPAA AUTHORIZATION TO DISCUSS YOUR MEDICAL INFORMATION

Transcription:

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 USES AND DISCLOSURES OF HEALTH INFORMATION We may use or disclose health information about you for treatment, payment, and healthcare operations. For example: Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you, or to family or friends you approve. Payment: We may use or disclose your health information to obtain payment for services we provide to you. Healthcare Operations: We may use or 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 credentialing activities. Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. You also have the right to request restrictions on disclosure of PHI (Personal Health Information), or alternative means of communication to ensure privacy. Marketing Heath-Related Services: We will not use your health information for marketing communications without your written authorization. Required by Law: We may use or disclose your health information if we are required to do so by law or national security activities. Abuse or Neglect: We may disclose your health information to appropriate authorities when we suspect abuse or neglect. Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters). PATIENT RIGHTS Access: You have the right to look at or get copies of your health information with limited exceptions. If you request copies, we will charge you a reasonable fee to locate and copy your information, and postage if you want the copies mailed to you. Amendment: You have the right to request that we amend your health information. Questions and Complaints If you want more information about our privacy practices or if you have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. Upon request, we can provide you with the address to file your complaint with the U.S. Department of Health and Human Services. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with the U.S. Department of Health and Human Services. A Privacy/Contact Officer has been designated for this office. Please ask our front desk personnel and they will direct you to the Privacy/Contact Officer. PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT FOR NECESSARY USE OF PERSONAL HEALTH INFORMATION Print Patient s Name Date I,, have received (Signature of Patient or Parent or Legal Guardian) a copy of this office s NOTICE OF PRIVACY PRACTICES as required by federal law. I,, consent to the use and disclosure of (Signature of Patient or Parent or Legal Guardian) my personal health information by your office during Treatment, Billing/Payment and Healthcare Operations as outlined in the Notice of Privacy Practices Contact Information: Ira G. Spiro 830 West End Court Suite 800 Vernon Hills, IL 60061 847-949-7305

Ira G. Spiro, D.D.S Simona Cheskis, D.D.S. 830 West End Court Suite 800 Vernon Hills, IL 60061 847-949-7305 Financial Policy Payment Full payment is due at the time services are rendered. We do not offer payment plans but we offer CareCredit and Lending Club as an additional method of payment. Returned checks will be charged a $25 fee. Balances over 60 days will be subject to a 10% late fee of the unpaid amount. Delinquent balances over 90 days will be referred to our collection agency and a recovery fee of 30% of the outstanding balance will be incurred. The outstanding balance will have to be paid in full for the patient to continue receiving dental treatment in our office. Insurance As a courtesy to our patients, we will submit your dental insurance. However, the patient is ultimately responsible for payment even if the claim is rejected. Due to the complexity of insurance contracts, we can only estimate in good faith. Estimated patient portion is expected at the time service is delivered. If the insurance company does not pay the anticipated amount, the patient is responsible for the difference. If you have any questions regarding your account, feel free to call our office for an explanation. I have read, understand and agree to comply with the above policy Patient Name Patient/Guardian Signature Date Ira G. Spiro, D.D.S Simona Cheskis, D.D.S. 830 West End Court Suite 800 Vernon Hills, IL 60061

847-949-7305 Cancellation/No Show Policy We understand that unplanned issues can come up and you may need to cancel an appointment. If that happens, we respectfully ask for scheduled appointments to be cancelled AT LEAST 24 HOURS IN ADVANCE. Our doctors and hygienists want to be available for your needs and the needs of all our patients. When a patient does not show up for a scheduled appointment, another patient loses an opportunity to be seen. Thank you for being a valued patient and for your understanding and cooperation! 1 st time - Warning 2 nd time - $50 Fee 3 rd time - $50 fee and possible termination from practice I have read, understand and agree to comply with the above policy Patient Name Patient/Guardian Signature Date

2024 © financedocbox.com Privacy Policy | Terms of Service | Feedback