PATIENTS WITH DENTAL INSURANCE REVIEW & SIGN
The major objective of our office is to provide you with the best quality dental care available anywhere. This service is based on a friendly, mutual, but business-like understanding between Doctor and patient.
In order to prevent misunderstandings, we would like you to read the following and sign the acknowledgment at the bottom. We would like to explain our policy regarding your dental insurance. As a courtesy, we will file your claim for you. We can only file claims on your behalf The benefits belong to you, and it is up to you to ensure that you are receiving appropriate reimbursement under the terms of your specific plan. We encourage you to verify your benefits with your carrier if you have any concerns as to the coverage they offer you in our office.
We are not a Medicare provider; and as such, claims from this office cannot be submitted to Medicare.
❖ Co-payment will be due at the time service is rendered. In certain instances, we can make payment arrangements if necessary. If this is necessary please talk this over with the office manager prior to yourtreatment.
❖ Your insurance company is only giving us an estimate based on their benefit structure and they also will not guarantee payment in advance. Therefore we can only give you an estimate of payment and your co-payment amount. Once again, it is not a guarantee of payment, as your insurance will not give any provider a guarantee of payment.
❖ Your policy is a contract between you and your carrier. Professional services are rendered to a person, not an insurance company. Therefore, the patient is responsible to us for payment. The insurance company is responsible to you for their contract benefits.
❖ Your insurance will be billed immediately upon completion of your treatment. If your insurance does not pay us within 90 days of the date of service, you are responsible for the balance at that time. We will instruct your carrier to remit their portion directly to you in this case. Most all carriers remit their payment within 40/60 days.
❖ We do not carry balances over 90 days from the date service is provided. We can only estimate your copayment not guarantee it. If our estimate differs from the insurance company's actual payment you are still responsible for that difference.
I have read and understood the above policy. (If you have any questions please ask the office manager prior to signing)
Both Doctor and Patient are encouraged to discuss any and all patient health issues prior to treatment. I certify that I have read and understood the above. I will not hold my dentist or any member of his staff, responsible for actions they take or do not take because of errors or omissions that I may have made in completing and updating this form.
If the patient under the age of 18, the signature of a parent or legal guardian required
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 01/18/2007, 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 the 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.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.
We use and 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.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
Healthcare Operations: We may use and 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. If you give us 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 was 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. We may disclose your health information to a family member, friend, or another person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
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 will not use your health information for marketing communications without your written authorization.
Required by Law: We may use or disclose your health information when we are required to do so by law.
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 authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to the correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).
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 using the contact information listed at the end of this Notice. 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 to the address at the end of this Notice. If you request copies, we will charge you $0.25 for each page, $30 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative 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 using the information listed at the end of this Notice for a full explanation of our fee structure.
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge yo1..ra 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 an emergency).
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 a satisfactory explanation of how payments will be handled under the alternative means or location you request.
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.
Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or 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 or 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. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.
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 us or with the U.S. Department of Health and Human Services.
I acknowledge reading the HIPPA Notice of Private Practices
One CBCT scan provides about 500 small x-ray images of the tooth: each one is called a slice. We can reconstruct an internal view of the tooth using several slices, rendering a 3-D image. The image can then be rotated on a computer screen and viewed from any angle.
The amount of radiation from a CBCT scan is equivalent to 5 days of background radiation or 2 days of direct sunlight that we would experience in everyday life. Due to its size, the amount of radiation from the CBCT is drastically less than that of the larger CT scan you would have in a hospital setting. The CBCT uses a cone-shaped x-ray beam to capture the target area and limit secondary exposure to other areas. The information gained from our 3-D technology gives us many advantages and aids in the successful treatment of your tooth.
If Dr. Lies /Dr. Garrett feels the scan is essential in your case, after reviewing your conventional x-rays, they will advise you of the reasons it is indicated.
Please review and sign the consent. Your signature on the attached page does NOT commit you to the scan. Only that if the Dr. feels it is necessary and you concur after conversing with him, will the scan be taken.
The fee for this procedure is $175.00 and it is NOT an insurance-covered benefit. We are proud to offer this extremely helpful, modern diagnostic tool.
A CBCT scan---also called cone beam computerized tomography -is an X-ray technique that produces 3D images that allows visualization of internal bony structures in cross-section rather than as overlapping images typically produced by conventional x-ray exams.
A conventional X-ray of your mouth limits your dentist to a two-dimensional (2D) view. Diagnosis and treatment planning can require a more complete understanding of a complex 3D anatomy. By way of example, a CBCT scan can provide significant 3D information which may be used by your treating dentist in assessing your condition, when planning for dental implants, surgical extractions, maxillofacial surgery, root canal treatment, or advanced dental restorative procedures. CT scans are also useful in looking at and potentially diagnosing conditions that can be missed on a conventional x-ray. The CBCT scan can enhance your dentist's ability to see what he/she needs to see before treatment is started.
WOMEN: CBCT scans are NOT recommended for pregnant women because of danger to the fetus.
CBCT scans, like conventional X-rays, expose you to radiation. The amount of radiation you will be exposed to is approximately the equivalent to what you would receive from two days of the sun. At our office, the dose of radiation used for CBCT is carefully controlled to ensure the smallest possible amount is used that will still give a useful result. An alternative to a CBCT scan are conventional dental x-rays, however, they have the limitations previously noted.
While parts of your anatomy beyond your mouth and jaw may be seen on the scan, your dentist is not a physician or specialist to make assessments concerning your anatomy beyond your mouth or jaw. If the report raises a question as to something unusual outside the specific area of the mouth or jaw, your dentist may refer you to a physician for an evaluation. In such an event, our office can place the image on a CD. You should also understand that CBCT images do not show most soft tissues or fluids, so some problem areas may have to be imaged with other methods.
DO NOT SIGN THIS FORM UNLESS YOU HAVE READ IT, UNDERSTAND IT, AND AGREE WITH WHAT IT SAYS
I, being 18 years or older, certify that I have read this consent form and that I understand the procedure to be performed, and its benefits, risks, and alternatives. I acknowledge that I will have had a full opportunity to discuss this procedure with the Dr. and will have had any/all questions answered to my satisfaction. Thus, I give my informed consent to perform the CBCT scan if necessary.
I understand root canal therapy is a procedure that retains a tooth, which may otherwise require extraction. As a specialty practice, this office performs only endodontic therapy and associated surgery. Although root canal therapy has a very high degree of success, results cannot be guaranteed.
Occasionally, a tooth, which has had root canal therapy, may require retreatment, surgery, or even extraction. Following treatment, the tooth may be brittle and subject to fracture. A restoration (filling), crown, and/or post and core will be necessary to restore the tooth, and your general dentist will perform these procedures. During endodontic treatment, there is the possibility of instrument separation within the root canals, perforations ( extra openings), damage to bridges, existing fillings, crowns or porcelain veneers, missed canals, loss of tooth structure in gaining access to canals, and fractured teeth. Also, there are times when a minor surgical procedure may be indicated or when a tooth may not be amenable to endodontic treatment at all. Other treatment choices include no treatment, a waiting period for more definitive symptoms to develop, or tooth extraction. Risks involved in those choices might include but are not limited to, pain, infection, swelling, loss of teeth, and infection in other areas. Occasionally, medication will be prescribed.
Medications prescribed for discomfort and/or sedation may cause drowsiness, which will be increased by the use of alcohol or other drugs. We advise that you do not operate a motor vehicle or any hazardous device while taking such medications. In addition, certain medications may cause allergic reactions, such as hives or intestinal discomfort. If any of these problems occur, call the office immediately. It is the patient's responsibility to report any changes in his/her medical history to the Dr.
Furthermore, I give West View Endodontics my permission to take digital photos of my procedure for purposes of completing my medical record and/or for patient education.
All accounts must be paid in full at the time treatment is rendered unless special arrangements are made prior to any treatment. Accounts 90 days past due are subjected to a 17% interest charge, and/or, transition to a collection recovery agency.