NOTE: This authorization is intended to comply with applicable state laws. It is not intended as a "Consent" or "Authorization" for the use and disclosure of Protected Health Information (PHI) under the federal Health Insurance Portability and Accountability Act Of 1996 (HIPAA) or its implementing regulations. The medical provider to whom this authorization is directed should ensure that he or She is in compliance with applicable HIPAA requirements before releasing the requested records.

Office hours are by appointment and we do value your time. This office is a private practice dental office and not a dental "clinic". Appointment time is reserved for you alone. Where appropriate, we Prefer to schedule longer appointments so we can complete as much needed dental treatment as possible during one appointment. We feel this type of scheduling will cause minimal disruption to your daily schedule and will provide efficiency in completing your dental care. When you make an appointment, please be sure that you will be able to keep it. Morning appointments are best for more complicated procedures.

Emergencies and unforeseen patient treatment problems may arise, causing schedule changes. Emergencies are unexpected and seem to come at the most inconvenient times. If you have a dental emergency that needs immediate attention, we will always offer to see you at once. We expect that other patients who might be slightly inconvenienced by this will understand the emergency situation. At some point, they may need the same courtesy too!

We will try and confirm your appointment 2 days in advance. If we are unable to get a confirmation verbally or through our automated system 24hrs prior to your appointment we may reschedule you at our discretion. Please make a note of any dental appointments we have scheduled in a place where you will be easily reminded. If you cannot make an appointment as scheduled, please notify the office. There will be a charge of $25 per 30 minutes of scheduled time for a broken appointment or cancellation with less than 24 hours notice for appointments.

If you have any questions about our appointment cancellation and no-show policy, please feel free to ask us. 

I consent to the use or disclosure of my protected health infomation by Dentistry on Western Center, its employees and staff for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct the health care operations on Western Center. I understand that diagnosis or treatment of me by Dentistry on Western Center may be conditioned upon my consent as evidenced by my signature on this document.

I understand that I have the right to request restriction as to how my protected health information is used or disclosed to carry out treatment, payment, or healthcare operations of the practice. Dentistry on Western Center is not required to agree to the requested restrictions. However, if my doctor agrees to a requested restriction, the restriction is binding.

I have the right to revoke this consent, in writing, any time, except to the extent that Dentistry on Western Center, it's employees, doctors, and staff have taken action in reliance on this consent.

My "protected health information" means health information, including my demographic information, collected from me and created or received by my doctor, another healthcare provider, a health plan, my employer or healthcare clearinghouse. This protected health information relates to my past, present, or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me. Your appointment may be recorded for quality contol purposes.

I understand I have the right to review Dentistry on Western Center's Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health infomation. That will occur in my treatment, payment of my bills or in the performance of health care operations of Dentistry on Western Center. The Notice of Privacy Practices also describes my rights and the practice's duties with respect to my protected healthcare information.

Dentistry on Western Center reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the Office and requesting a revised copy be sent in the mail or by asking for one at the time of my next appointment.