OFFICE FINANCIAL POLICY

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Transcription:

OFFICE FINANCIAL POLICY DDS Baltazar Guzman In our continue commitment to provide the highest quality dental care available to all of our patients and to have those services comfortably affordable, we are pleased to offer you these options for payment. PERSONAL CREDIT CARDS VISA CARD - MASTERCARD - AMEX- PERSONAL CHECKS - CASH PREPAYMENT We are happy to offer a 5% discount for all services over $1000.00 when prepaid in full upon scheduling and with patient taking responsibility of insurance claim & billing. We are committed to support you in understanding your dental health, so that you will always be able to make the best dental choices. We will, as a courtesy, process your insurance benefits in our office, which will relieve you of this time consuming and sometimes complicated process I agree that I am fully responsible for the total payment of all procedures performed in this office this includes any treatment that is not a benefit of any dental insurance that I may have. I understand that all services are due to be paid in full within (60) days of the date of the service, regardless of whether or not my insurance benefits have been received. One and one-half percent (1.5%) per month interest (18% per year) will be charged on accounts 60 days from treatment date. INSURANCE As a courtesy to our patients, we will bill your insurance company. Your insurance policy is a contract between you and your insurance company. As a healthcare provider, we are not a party to that agreement. Signature (Responsible Party) Date Signature (Financial Coordinator) Date

MISSED APPOINTMENTS Appointment times are reserved especially for you. If for any reason you should need to change your appointment, you will not be charged $100, provided you give us a minimum two business days notice. Should you give no notice or no show, for an appointment, there will be a $150 charge. Please help us serve you better by keeping your scheduled appointments. We are here to assist you in any way possible. Please make your questions and concerns known to our team Our goal is to ensure that you have an outstanding experience. Print name Signature (Responsible Party) Date

X-Ray Policy At Baltazar Guzman Dental Office your dental health is our priority! To make an appropriate dental diagnosis, adequate x-rays must be taken of your teeth and surrounding structures. We adhere to the following protocol to maintain quality of care: All new patient comprehensive exams will require a Full Mouth Series (FMX) of x-rays. An FMX, consisting of 18 films, provides a detailed view of the teeth, their roots, and the surrounding bony structures, and is taken every 3-5 years. Existing patients will require a minimum biannual check-up x-rays of four (4) Bitewing and four (4) periapical xray each year for up to 3-5 years following an FMX. Periodontal conditions, extent of existing dental work, and other factors may necessitate the need for an FMX or additional x-rays on a more regular basis. initial here X-rays taken prior to your initial visit may be used to satisfy the need for required x-rays at our office. As a courtesy our staff will be happy to assist you in obtaining copies of prior x-rays. Please note that required x-rays must be taken in order to continue treatment with us, regardless of your insurance coverage. It is a violation of state law to treat a patient without adequate x- rays. initial here State law also dictates that a patient cannot consent to negligent treatment. Therefore, refusal of necessary x-rays will constitute termination of the doctor patient relationship. We appreciate your understanding of this policy. Staff members will be happy to answer any questions you may have. initial here Signature (Responsible Party) Date

Patient Acknowledgement of Receipt of Dental Materials Fact Sheet I,, acknowledge that I have received a copy of the Dental Materials Fact Sheet dated May 2004 from the office Dr. Baltazar Guzman. Patient Signature Date The following document is the Dental Board of California's Dental Materials Fact Sheet. The Department of Consumer Affairs has no position with respect to the language of this Dental Material Fact Sheet; and its linkage to the DCA website does not constitute an endorsement of the content of this document. The Dental Board of California Dental Materials Fact Sheet Adopted by the Board on May 2004 As required by Chapter 801, Statutes of 1992, the Dental Board of California has prepared this fact sheet to summarize information on the most frequently used restorative dental materials. Information on this fact sheet is intended to encourage discussion between the patient and dentist regarding the selection of dental materials best suited for the patient s dental needs. It is not intended to be a complete guide to dental materials science. The most frequently used materials in restorative dentistry are amalgam, composite resin, glass ionomer cement, resin-ionomer cement, porcelain (ceramic), porcelain (fused-to-metal), gold alloys (noble) and nickel or cobalt-chrome (base-metal) alloys. Each material has its own advantages and disadvantages, benefits and risks. These and other relevant factors are compared in the attached matrix titled "Comparisons of Restorative Dental Materials." A Glossary of Terms" is also attached to assist the reader in understanding the terms used. The statements made are supported by relevant, credible dental research published mainly between 1993-2001. In some cases, where contemporary research is sparse, we have indicated our best perceptions based upon information that predates 1993. The reader should be aware that the outcome of dental treatment or durability of a restoration is not solely a function of the material from which the restoration was made. The durability of any restoration is influenced by the dentist s technique when placing the restoration, the ancillary materials used in the procedure, and the patient s cooperation during the procedure. Following restoration of the teeth, the longevity of the restoration will be

Acknowledgement of Receipt of Notice of Privacy Practices **You May Refuse to Sign This Acknowledgement** I,, have received a copy of the Baltazar Guzman DDS Notice of Privacy Practices. Patient Signature Date If this Acknowledgement is signed by a personal representative on behalf of the patient, complete the following: Personal Representative's name Relationship to Patient For Program Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify) Notice of Privacy Practices This Notice describes how your health information 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. Our Legal Duty Federal and state laws require us to maintain the privacy of your health information. We are also required to provide this Notice about our office s privacy practices, our legal duties, and your rights regarding your health information. We are required to follow the practices that are outlined in this Notice while it is in effect. This Notice takes effect 09/23/2013 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 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 make the new Notice available upon request. For more information about our privacy practices or additional copies of this Notice, please contact us (contact information below). Uses and Disclosures of Health Information We use and disclose health information about you for treatment, payment, and healthcare operations. For example: Treatment: We disclose medical information to our employees and others who are involved in providing the care you need. We may use or disclose your health information to another dentist or other healthcare providers providing treatment that we do not provide. We may also share your health information with a pharmacist in order to provide you with a prescription, or with a laboratory that performs tests or fabricates dental prostheses or orthodontic appliances. Payment: We may use and disclose your health information to obtain payment for services we provide you; unless you request that we restrict such disclosure to your health plan when you have paid out-of-pocket and in full for services rendered. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include, but are not limited to, quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, and 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. 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 is 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. To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. You have the right to request restrictions on disclosure to family members, other relatives, close personal friends, or any other person identified by you. Unsecured Email: We will not send you unsecured emails pertaining to your health information without your prior authorization. If you do authorize communications via unsecured email, you have the right to revoke the authorization at any time. Persons Involved in Care:

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 incapacity or 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. Marketing Health-Related Services: We may contact you about products or services related to your treatment, case management or care coordination, or to propose other treatments or health-related benefits and services in which you may be interested. We may also encourage you to purchase a product or service when you visit our office. If you are currently an enrollee of a dental plan, we may receive payment for communications to you in relation to our provision, coordination, or management of your dental care, including our coordination or management of your health care with a third party, our consultation with other health care providers relating to your care, or if we refer you for health care. We will not otherwise use or disclose your health information for marketing purposes without you written authorization. We will disclose whether we receive payments for marketing activity you have authorized. Change of Ownership: If this dental practice is sold or merged with another practice or organization, your health records will become the property of the new owner. However, you may request that copies of your health information be transferred to another dental practice. Required by Law: We may use or disclose your health information when we are required to do so by law. Public Health: We may, and are sometimes legally obligated, to disclose your health information to public health agencies for purposes related to preventing or controlling disease, injury or disability; reporting abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure. Upon reporting suspected elder or dependent adult abuse or domestic violence, we will promptly inform you or your personal representative unless we believe the notification would place you at risk of harm or would require informing a personal representative we believe is responsible for the abuse or harm. Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorize federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional

institutions or law enforcement officials having lawful custody of protected health information of inmates or patients under certain circumstances. Appointment Reminders: We may contact you to provide you with appointment reminders via voicemail, postcards, or letters. We may also leave a message with the person answering the phone if you are not available. Sign In Sheet and Announcement: Upon arriving at our office, we may use and disclose medical information about you by asking that you sign an intake sheet at our front desk. We may also announce your name when we are ready to see you. Patient Rights Access: 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 contacting our office. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter. If you request copies, there may be a charge for time spent. If you request an alternate format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us for a full explanation of our fee structure. Disclosure Accounting: You have a right to receive a list of instances in which we disclosed your health information for purposes other than treatment, payment, healthcare operations and certain other activities for the last six years. 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.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in emergency). In the event you pay out-of-pocket and in full for services rendered, you may request that we not share your health information with your health plan. We must agree to this request. Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. Breach Notification: In the event your unsecured protected health information is breached, we will notify you as required by law. In some situations, you may be notified by our business associates. Amendment: 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 deny your request under certain circumstances.

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