This AGREEMENT is for the purpose of identifying any express or implied agreement,
including, but not limited to, permission, consent, release, and/or authorization between DENTIST/PRACTICE and PATIENT in connection with the medical services PATIENT received from DENTIST/PRACTICE.
DENTIST/PRACTICE and PATIENT warrant and represent that PATIENT has given CONSENT and FULL AUTHORIZATION that any photographs and/or images of PATIENT, under the following conditions.
1. The photographs and/or images & videos will be taken by DENTIST/PRACTICE or by a photographer and/or skilled operator approved by DENTIST/PRACTICE.
2. The photographs and/or images may be used for:
a. Identification purposes, medical records, and if in the judgment of DENTIST/PRACTICE, medical research, education or science will be benefited by their use. Such photographs and/or images and information relating to PATIENT may be published or republished, either separately or in connection with each other, in but not limited to, professional journals, medical books, medical based Internet websites, or any other purpose which DENTIST/PRACTICE may deem proper in the interest or, but not limited to, medicaleducation, knowledge, or research; and or
b. PATIENT further authorizes that the photographs and/or images may be used by DENTIST/PRACTICE or by an entity approved by DENTIST/PRACTICE in promotional printed, computer website and/or video material.
3. At no time will PATIENT’S name, address, or any other alpha/numeric PATIENT identifiableinformation be used in connection with the publication of the photographs and/or images of PATIENT. PATIENT acknowledges the possibility that his/her identity may become known as a result of the publication and use of the photographs and/or images described in paragraph 2; above.
4. The photographs and/or images & video may be modified and/or retouched in any way in DENTIST’S/PRACTICE discretion.
By signing below, PATIENT certifies that he/she has read and understood each and everysection of this Agreement, and agrees to be bound by its terms.
We are committed to providing you with the best possible care and would be happy to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions about our fees, financial policy, or your financial responsibility. If you do not have insurance, we expect payment in full for all treatment at the time of service, unless other arrangements have been previously made. We have created an online payment service through our website at (insert url here
If you have insurance, we can assist you in submitting your claim. Your insurance claim will only be completed and submitted if we are provided with all pertinent insurance company information. It is your responsibility to verify that your policy is in effect at the time your services are performed. Otherwise, you are responsible for payment at the time of service.
Insurance is an agreement between you and your insurance company. We will inform you if we are participating with your insurance plan and will handle your claim according to our agreement with the insurance company. We file insurance claims as a courtesy to you, our patient. We will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, maximum limitations, covered charges, secondary insurances, “usual and customary” charges, etc., other than to supply necessary factual information. If payment is not received from your insurance company by us within a reasonable period of time, the balance of the account becomes your responsibility. I hereby authorize and agree as follows:
I have read the above Financial Policy and understand that I am financially responsible for all charges, whether or not they are paid by my insurance.
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.
We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices that are described 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, and to make new Notice provisions effective for all protected health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new Notice 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.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
We may use and disclose your health information for different purposes, including treatment, payment, and health care operations. For each of these categories, we have provided a description and an example. Some information, such as HIV-related information, genetic information, alcohol and/or substance abuse records, and mental health records may be entitled to special confidentiality protections under applicable state or federal law. We will abide by these special protections as they pertain to applicable cases involving these types of records.
Treatment. We may use and disclose your health information for your treatment. For example, we may disclose your health information to a specialist providing treatment to you.
Payment. We may use and disclose your health information to obtain reimbursement for the treatment and services you receive from us or another entity involved with your care. Payment activities include billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your dental health plan containing certain health information.
Healthcare Operations. We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, conducting training programs, and licensing activities.
Individuals Involved in Your Care or Payment for Your Care. We may disclose your health information to your family or friends or any other individual identified by you when they are involved in your care or in the payment for your care. Additionally, we may disclose information about you to a patient representative. If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information.
Disaster Relief. We may use or disclose your health information to assist in disaster relief efforts.
Required by Law. We may use or disclose your health information when we are required to do so by law.
Public Health Activities. We may disclose your health information for public health activities, including disclosures to: oPrevent or control disease, injury or disability; oReport child abuse or neglect; oReport reactions to medications or problems with products or devices; oNotify a person of a recall, repair, or replacement of products or devices; oNotify a person who may have been exposed to a disease or condition; or oNotify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.
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 correctional institution or law enforcement official having lawful custody the protected health information of an inmate or patient.
Secretary of HHS. We will disclose your health information to the Secretary of the U.S. Department of Health and Human Services when required to investigate or determine compliance with HIPAA.
Worker’s Compensation. We may disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.
Law Enforcement. We may disclose your PHI for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order. Health Oversight Activities. We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Judicial and Administrative Proceedings. If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about the request or to obtain an order protecting the information requested.
Research. We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information.
Coroners, Medical Examiners, and Funeral Directors. We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties.
Fundraising. We may contact you to provide you with information about our sponsored activities, including fundraising programs, as permitted by applicable law. If you do not wish to receive such information from us, you may opt out of receiving the communications.
OTHER USES AND DISCLOSURES OF PHI
Your authorization is required, with a few exceptions, for disclosure of psychotherapy notes, use or disclosure of PHI for marketing, and for the sale of PHI. We will also obtain your written authorization before using or disclosing your PHI for purposes other than those provided for in this Notice (or as otherwise permitted or required by law You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization.
YOUR HEALTH INFORMATION RIGHTS
Access. You have the right to look at or get copies of your health information, with limited exceptions. You must make the request in writing. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice. If you request information that we maintain on paper, we may provide photocopies. If you request information that we maintain electronically, you have the right to an electronic copy. We will use the form and format you request if readily producible. We will charge you a reasonable cost-based fee for the cost of supplies and labor of copying, and for postage if you want copies mailed to you. Contact us using the information listed at the end of this Notice for an explanation of our fee structure. If you are denied a request for access, you have the right to have the denial reviewed in accordance with the requirements of applicable law.
Disclosure Accounting. With the exception of certain disclosures, you have the right to receive an accounting of disclosures of your health information in accordance with applicable laws and regulations. To request an accounting of disclosures of your health information, you must submit your request in writing to the Privacy Official. 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 the additional requests.
Right to Request a Restriction. You have the right to request additional restrictions on our use or disclosure of your PHI by submitting a written request to the Privacy Official. Your written request must include (1) what information you want to limit, (2) whether you want to limit our use, disclosure or both, and (3) to whom you want the limits to apply. We are not required to agree to your request except in the case where the disclosure is to a health plan for purposes of carrying out payment or health care operations, and the information pertains solely to a health care item or service for which you, or a person on your behalf (other than the health plan), has paid our practice in full.
Alternative Communication. You have the right to request that we communicate with you about your health information by alternative means or at 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. We will accommodate all reasonable requests. However, if we are unable to contact you using the ways or locations you have requested we may contact you using the information we have.
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. If we agree to your request, we will amend your record(s) and notify you of such. If we deny your request for an amendment, we will provide you with a written explanation of why we denied it and explain your rights.
Right to Notification of a Breach. You will receive notifications of breaches of your unsecured protected health information as required by law.
Electronic Notice. You may receive a paper copy of this Notice upon request, even if you have agreed to receive this Notice electronically on our Web site or by electronic mail (e-mail
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 if 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.
Our Privacy Official: Dr. Michael Verber
Phone: 717.737.4337 Fax: 717.737.4337
Address: 3920 Market Street, Camp Hill, PA 17011
I had the opportunity to review and/or obtain a copy of this office’s Notice of Privacy Practices.
* You May Refuse to Sign This Acknowledgment*
In providing dental care, we will treat your child as we would our own. Dentistry is animportant health service for your child, and it is our goal to provide him/her with a satisfyingexperience in our office. Please read this form carefully. Should you have any questions, ouroffice staff will be delighted to help you.
1. I hereby authorize and direct doctors and staff at Verber Family Dentistry to perform dental treatment with the use of any necessary or advisable radiographs (x-rays) and/or any otherdiagnostic aids in order to complete a thorough diagnosis and treatment plan. I understandcertain parts of the treatment may be performed by dental assistants and hygienists.
2. I understand x-rays, photographs, models of the mouth, and/or any other diagnostic aid used for an accurate diagnosis and treatment planning are the property of the doctor, but copies are available upon request.
3. In general terms, the dental procedure(s) can include but not be limited to comprehensive oral examination, radiographs, cleaning of the teeth and the application of topical fluoride, application of sealants to the grooves of the teeth, treatment of diseases or injured teeth with dentalrestorations, stainless steel or composite crowns and/or root canal treatment, oral surgery,extraction of one or more teeth, excision of hyperplastic and/or pericoronal tissue, exposure of unerupted tooth, placement of space maintainers and/or replacement of missing teeth withdental prosthesis, treatment of diseases or injured oral tissues secondary to traumatic injuries and/or accidents and/or infection, treatment of habits, malposed (crooked) teeth, orthodontics and/or oral dental development or growth abnormalities.
4. I authorize the use of accepted behavior management techniques including nitrous oxideanalgesia in order to complete treatment for my child. I understand that the doctor is notresponsible for previous dental treatment. I understand that in the course of treatment, thispreviously existing dentistry may need adjustment and/or replacement. I realize that guarantees of results or absolute satisfaction are not possible in dental health service.
5. I have answered all the questions about my or me dependent’s medical history and present health condition fully and truthfully. I have told the dentist or other office personnel about all conditions, including allergies, which might indicate that my child should receive oralmedications. I also understand if I or my dependent ever had any changes in health status or any changes in medication(s) I will inform the doctor at the next appointment.
6. I authorize other individuals with whom I have places the care of my child, such as otherfamily members, caregivers to sign consent for dental treatment for my child should they bring my child to any future appointments.
I hereby acknowledge that I have read & understand this consent and the meaning of it’scontents. All questions have been answered in a satisfactory manner and I believe I havesufficient information to give informed consent for treatment. I further understand that thisconsent shall remain in effect until terminated by me.