Appointment Confirmation Policy Our Office strives to be respectful of each patient s time. When patients do not show up for their scheduled appointments or are late to notify our office of a cancelation, it delays care for our patients that are waiting for treatment. We respectfully require scheduled appointments to be confirmed at least 24 hours in advance. Appointments not confirmed within 24 hours will be released. Failed appointments will be subject to a $35 fee. We accept confirmation by phone call, text message, or email. Please leave a message on our office answering machine after hours to confirm an appointment. We greatly thank you for being a valued patient and for your understanding and cooperation. Please sign and date once you have read and agreed to the terms and conditions above. Sign. Date:
Consent for Internet Communications We are very concerned with protecting your privacy. While the law requires us to give you this disclosure, please understand that we have, and always will respect the privacy of your health information. There are several circumstances in which we may have to use or disclose your health care information: We may have to disclose your health information to another health care provider or a hospital if it is necessary for our office to refer you to them for consultation or treatment. We may have to disclose your health information and billing records to another party if they are potentially responsible for the payment of your service. Please list any person we can communicate this information with. If there is no one you would like us to communicate with please write none. o We may need to use your personal information to remind you of your appointments. I understand that all email communications in which I engage may be forwarded to other providers for the purposes of providing treatment to me. This may include but not be limited to sending your x-rays and/or minimal personal information to other providers via email. We strive to keep all patient information secure but unfortunately there is no assurance of confidentiality of information when communicating this way. I have read and understand this policy and agree to the terms. Sig.
Financial Policy Welcome to the office of Dr. Pamela Ottesen. It is the intention of our staff to provide you with thorough and effective dental care. Please let us know if there is anything we can do to assist you in optimal dental care. Our office staff strives to make every effort to advise you of your estimated financial responsibility. If at anytime you have any questions about treatment or financial estimates please notify a staff member promptly, as we value an open and honest financial relationship with all of our patients. Payments accepted: 1. Cash 2. Check 3. Visa/Master Card/ Discover Card/ Amex 4. Care Credit Insurance: Dr. Ottesen is a contracted provider for a variety of insurance companies that aid in the payment of your dental cost. Our office can provide you with the courtesy of filing, however we do recognize that your dental insurance is an agreement between you and your employer and you are ultimately responsible for all dental fees relating to your care. Please note that regardless of dental insurance coverage, our office relies on you for settling your account. All deductibles and copayments are due at time of service. If you do not have insurance, your balance is due at time of service. Treatment Estimates: Our staff strives to give the closest estimate of treatment financial responsibility based on what information the insurance company provides to us. However, we can file a pretreatment claim to your carrier to get a closer estimate figure. This process usually takes 2-3 weeks. Please feel free to request this service. I understand this policy and agree to comply: X Date:
General Consent for Dental Treatment I, the undersigned, understand and authorize the doctor to take radiographs (xrays), study models, photographs, or any other diagnostic aids deemed appropriate to make a thorough diagnosis of my needs. I also authorize the doctor to perform any and all forms of treatment, medication, and therapy that may be indicated. I assume the right and responsibility to ask for any risks of treatment, alternative treatments, as well as the financial responsibility of the treatments. I understand that the use of local anesthetics embody a certain risk. Complications and side effects are rare, but may include, among others not listed: Swelling, bruising or soreness at the injection site, numbness outside of the mouth, temporary rapid heart beat, damages to the nerves resulting in temporary or possibly permanent numbness or tingling of lips, chin, tongue or other areas, severe allergic and possible life threatening reactions necessitating emergency care. I understand that if I have high blood pressure, uncontrolled thyroid problems, angina or have recently had a heart attack that I will inform my dentist verbally without fail as these conditions have caused complications for persons receiving local anesthesia. I assume the right and responsibility to ask for any alternative treatments, as well as the financial responsibility of the treatments. I confirm that I am over the age of 18 years old (If not please stop and notify the front desk). I understand that I am responsible for payment for the services provided for myself, or my dependents and it is payable at the time of services rendered or by the Financial Policies guidelines that I have read and understand. I authorize payment to be issued by my insurance carrier directly to this office unless I pay at the time service is completed and asked for the assignment of benefits go to myself. I also understand that any balance from the insurance company that is not resolved after 30 days is my responsibility. In the event an account is turned over to an attorney, I agree to pay all reasonable attorney fees, court cost and other costs associated with the collection of the account. I had the opportunity to read and have it explained all HIIPA compliance polices. My signature acknowledges that I have asked and have had answered any and all questions associated with any of the above issues. X Date:
HIPPA Notice of Privacy Practices 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. I. Dental Practice Covered by this Notice This Notice describes the privacy practices of Ottesen Family Dentistry ( Dental Practice ). We and our means the Dental Practice. You and your means our patient. II. How to contact Us/Our Privacy Official If you have any questions or would like further information about this Notice, you can contact Ottesen Family Dentistry Privacy Official at: Pamela Ottesen (850) 279-6657 info@nicevilledental.com III. Our Promise to You and Our Legal Obligations The privacy of your health information is important to us. We understand that your health information is personal and we are committed to protecting it. This Notice describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected health information is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. We are required by law to: Maintain the privacy of your protected health information; Give you this Notice of our legal duties and privacy practices with respect to that information; and Abide by the terms of our Notice that is currently in effect. IV. Last Revision date This Notice was last revised on 7/1/2014
V. How We May use or Disclose Your Health Information The following examples describe different ways we may use or disclose your health information. These examples are not meant to be exhaustive. We are permitted by law to use and disclose your health information for the following purposes: A. Common Uses and Disclosures 1. Treatment. We may use your health information to provide you with dental treatment or services, such as cleaning or examining your teeth or performing dental procedures. We may disclose health information about you to dental specialists, physicians, or other health care professionals involved in your care. 2. Payment. We may use and disclose your health information to obtain payment from health plans and insurers for the care that we provide to you. 3. Health Care Operations. We may use and disclose health information about you in connection with health care operations necessary to run our practice, including review of our treatment and services, training, evaluating the performance of our staff and health care professionals, quality assurance, financial or billing audits, legal matters, and business planning and development. 4. Appointment Reminders. We may use or disclose your health information when contacting you to remind you of a dental appointment. We may contact you by using a postcard, letter, phone call, voice message, text or email. 5. Treatment Alternatives and Health-Related Benefits and Services. We may use and disclose your health information to tell you about treatment options or alternatives or healthrelated benefits and services that may be of interest to you. 6. Disclosure to Family Members and Friends. We may disclose your health information to a family member or friend who is involved with your care or payment for your care if you do not object or, if you are not present, we believe it is in your best interest to do so. 7. Disclosure to Business Associates. We may disclose your protected health information to our third-party service providers (called, business associates ) that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use a business associate to assist us in maintaining our practice management software. All of our business associates are obligated, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract. B. Less Common Uses and Disclosures 1. Disclosures Required by Law. We may use or disclose patient health information to the extent we are required by law to do so. For example, we are required to disclose patient health information to the U.S. Department of Health and Human Services so that it can investigate complaints or determine our compliance with HIPAA. 2. Public Health Activities. We may disclose patient health information for public health activities and purposes, which include: preventing or controlling disease, injury or disability;
reporting births or deaths; reporting child abuse or neglect; reporting adverse reactions to medications or foods; reporting product defects; enabling product recalls; and notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. 3. Victims of Abuse, Neglect or Domestic Violence. We may disclose health information to the appropriate government authority about a patient whom we believe is a victim of abuse, neglect or domestic violence. 4. Health Oversight Activities. We may disclose patient health information to a health oversight agency for activities necessary for the government to provide appropriate oversight of the health care system, certain government benefit programs, and compliance with certain civil rights laws. 5. Lawsuits and Legal Actions. We may disclose patient health information in response to (i) a court or administrative order or (ii) a subpoena, discovery request, or other lawful process that is not ordered by a court if efforts have been made to notify the patient or to obtain an order protecting the information requested. 6. Law Enforcement Purposes. We may disclose your health information to a law enforcement official for a law enforcement purposes, such as to identify or locate a suspect, material witness or missing person or to alert law enforcement of a crime. 7. Coroners, Medical Examiners and Funeral Directors. We may disclose your health information to a coroner, medical examiner or funeral director to allow them to carry out their duties. 8. Organ, Eye and Tissue Donation. We may use or disclose your health information to organ procurement organizations or others that obtain, bank or transplant cadaveric organs, eyes or tissue for donation and transplant. 9. Research Purposes. We may use or disclose your information for research purposes pursuant to patient authorization waiver approval by an Institutional Review Board or Privacy Board. 10. Serious Threat to Health or Safety. We may use or disclose your health information if we believe it is necessary to do so to prevent or lessen a serious threat to anyone s health or safety. 11. Specialized Government Functions. We may disclose your health information to the military (domestic or foreign) about its members or veterans, for national security and protective services for the President or other heads of state, to the government for security clearance reviews, and to a jail or prison about its inmates. 12. Workers Compensation. We may disclose your health information to comply with workers compensation laws or similar programs that provide benefits for work-related injuries or illness. VI. Your written Authorization for Any Other Use or Disclosure of Your Health Information
Uses and disclosures of your protected health information that involve the release of psychotherapy notes (if any), marketing, sale of your protected health information, or other uses or disclosures not described in this notice will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke this authorization at any time, in writing, except to the extent that this office has taken an action in reliance on the use of disclosure indicated in the authorization. If a use or disclosure of protected health information described above in this notice is prohibited or materially limited by other laws that apply to use, we intend to meet the requirements of the more stringent law. VII. Your Rights with Respect to Your Health Information You have the following rights with respect to certain health information that we have about you (information in a Designated Record Set as defined by HIPAA). To exercise any of these rights, you must submit a written request to our Privacy Official listed on the first page of this Notice. A. Right to Access and Review You may request to access and review a copy of your health information. We may deny your request under certain circumstances. You will receive written notice of a denial and can appeal it. We will provide a copy of your health information in a format you request if it is readily producible. If not readily producible, we will provide it in a hard copy format or other format that is mutually agreeable. If your health information is included in an Electronic Health Record, you have the right to obtain a copy of it in an electronic format and to direct us to send it to the person or entity you designate in an electronic format. We may charge a reasonable fee to cover our cost to provide you with copies of your health information. B. Right to Amend If you believe that your health information is incorrect or incomplete, you may request that we amend it. We may deny your request under certain circumstances. You will receive written notice of a denial and can file a statement of disagreement that will be included with your health information that you believe is incorrect or incomplete. C. Right to Restrict Use and Disclosure You may request that we restrict uses of your health information to carry out treatment, payment, or health care operations or to your family member or friend involved in your care or the payment for your care. We may not (and are not required to) agree to your requested restrictions, with one exception: If you pay out of your pocket in full for a service you receive from us and you request that we not submit the claim for this service to your health insurer or health plan for reimbursement, we must honor that request. D. Right to Confidential Communications, Alternative Means and Locations You may request to receive communications of health information by alternative means or at an alternative location. We will accommodate a request if it is reasonable and you indicate that communication by regular means could endanger you. When you submit a written request to the Privacy Official listed on the first page of this Notice, you need to provide an alternative method of contact of alternative address and indicate how payment for services will be handled. E. Right to an Accounting of Disclosures
You have a right to receive an accounting of disclosures of your health information for the six (6) years prior to the date that the accounting is requested except for disclosures to carry out treatment, payment, health care operations (and certain other exceptions as provided by HIPAA). The first accounting we provide in any 12-month period will be without charge to you. We may charge a reasonable fee to cover the cost for each subsequent request for an accounting within the same 12-month period. We will notify you in advance of this fee and you may choose to modify or withdraw your request at that time. F. Right to a Paper Copy of this Notice You have the right to a paper copy of this Notice. You may ask us to give you a paper copy of this Notice at any time (even if you have agreed to receive the Notice electronically). To obtain a paper copy, ask the Privacy Official. G. Right to Receive Notification of a Security Breach We are required by law to notify you if the privacy or security of your health information has been breached. The notification will occur by first class mail within sixty (60) days of the event. A breach occurs when there has been an unauthorized use or disclosure under HIPAA that compromises the privacy or security of your health information. The breach notification will contain the following information: (1) a brief description of what happened, including the date of the breach and the date of the discovery of the breach; (2) the steps you should take to protect yourself from potential harm resulting from the breach; and (3) a brief description of what we are doing to investigate the breach, mitigate losses, and to protect against further breaches. VII. Special Protections for HIV, Alcohol and Substance Abuse, Mental Health and Genetic Information Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including HIV-related information, alcohol and substance abuse information, mental health information, and genetic information. For example, a health plan is not permitted to use or disclose genetic information for underwriting purposes. Some parts of this HIPAA Notice of Privacy Practices may not apply to these types of information. If your treatment involves this information, you may contact our office for more information about these protections. IX. Our Right to Change Our Privacy Practices and This Notice We reserve the right to change the terms of this Notice at any time. Any change will apply to the health information we have about you or create or receive in the future. We will promptly revise the Notice when there is a material change to the uses or disclosures, individual s rights, our legal duties, or other privacy practices discussed in the Notice. We will post the revised Notice on our website (if applicable) and in our office and will provide a copy of it to you on request. The effective date of this Notice is 7/1/14. X. How to Make Privacy Complaints
If you have any complaints about your privacy rights or how your health information has been used or disclosed, you may file a complaint with us by contacting our Privacy Official listed on the first page of this Notice. You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you in any way if you choose to file a complaint. Sig. Date:
(850) 279-6657 info@nicevilledental.com Welcome to Ottesen family dentistry! We are so happy to welcome you as a new patient here at our family practice. Please read and fill out these forms accordingly. There will be a signature required on all consent forms. Thank you and have a wonderful visit! Patient s First and Last Name: Pref. Name: Sex: M / F Mailing Address: City: St: Zip: Home Phone: Cell: Work: Ext.: Email: Employer s Name: DOB: Soc. Sec: - - Insurance Company: Policy Holder s First and Last Name: Mailing Address: City: St: Zip: Employer s Name: DOB: Soc. Sec: - - Our office does require appointment confirmation. How would you prefer your confirmation? (Circle all that apply.) Text / Email / Phone