financialagreement

We appreciate you allowing us to provide dental care for your child. We wish to attract families to our practice that take an active role in their oral health and remain financially responsible. Because we value our relationship with you and believe that the best relationships are based on understanding, we offer these clarifications on methods of payment and insurance reimbursement.

  • If you have dental insurance to help with your payments, please bring your insurance card with you and notify us of any changes.
  • As a courtesy, we participate in many insurance plans and agree to the discounted treatment fees they offer for their subscribers. Furthermore, we will file insurance benefits for you. Many insurance companies will pay our office directly. However, some insurance companies may only reimburse you and not our office. If your insurance company will not reimburse our office, you will be responsible for the full cost of the visit at the time the services are provided. Your insurance company will then send you a reimbursement check directly.
  • Any amount determined not to be covered by your insurance company is payable at the time services are rendered. These fees may include:
    • Deductibles
    • Co-payments
    • Fees for procedures not covered by your insurance policy
  • We will allow a maximum of 45-days for your insurance company to clear account balances. Any unpaid portions will be due in full by you after this period.
  • Accepted methods of payment:
    • Cash
    • Money orders
    • Cashiers checks
    • Debit cards
    • Visa (credit card)
    • Master Card (credit card)
    • Personal checks
  • If a check is returned, the parent or guardian will be charged a $50 fee, for which they are responsible, in addition to their balance.
  • Financing Programs: To help provide cost-effective care, we offer financing programs for dental treatment. Please inquire about these programs.
  • Financial Obligation: After attempts to collect outstanding funds and a 90-day grace period from time of service, parents or guardians not fulfilling their financial obligation will be sent to collections and be responsible for paying the collection charges (38% plus any court costs that are incurred), in addition to their balance.
  • Prior to completing any treatment, we will provide you with a cost estimate indicating our total fee, what we expect insurance coverage to be, and your estimated financial obligation due on the day of service. This figure is only an estimate. Additional billing or refunds may be required. Any changes will be brought to your attention as soon as possible.

We look forward to working with you to maintain your child’s oral health!

privacypractices

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. If you have any questions about this Notice, please contact our Privacy Officer.

This Notice of Privacy Practices 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. We are required by Federal law to give you this Notice and to maintain the privacy of your health information. We must also abide by the terms of this Notice while it is in effect. We reserve the right to change our privacy practices and the terms of this Notice at any time. Before we make significant changes in our privacy practices, we will change this Notice and make the new Notice available upon request.

How We May Use and Disclosure Your Protected Health Information

When we give you our Notice of Privacy Practices, you will be asked to sign an Acknowledgement of Receipt. Once you have received our Notice and signed the Acknowledgement, we will use your protected health information for treatment, payment and health care operations. We may use or disclose your protected health information in an emergency treatment situation. If this happens, we will try to obtain your signature on the Acknowledgement of Receipt as soon as reasonably practicable after the delivery of treatment. The following examples show the types of uses and disclosures of your protected health information that our office is permitted to make.

Treatment: Your protected health information may be used and disclosed by our office and others outside of our office that are involved in your dental care. We will use and disclose your protected health information to other dentists and physicians to provide, coordinate, or manage your health care. For example, your protected health information may be provided to another dental specialist to whom you have been referred to ensure that the necessary information is available to diagnose or treat you.

Payment: Your protected health information may be used and disclosed to pay your health care bills. Your protected health information will be used to obtain payment for services we provide to you. This may include certain activities that your insurance plan may undertake before it approves or pays for the services we recommend. Healthcare Operations: We may use or disclose your protected health information in order to support the business activities of our practice. Healthcare operations include quality assessment activities, employee review activities, licensing or credentialing activities, conducting training and conducting auditing or review activities. For example, we may use a sign-in sheet at the reception desk where you will be asked to sign your name and indicate your doctor. We may also call your name in the waiting room when your doctor is ready to see you. We may send you reminder postcards or telephone you to remind you of an appointment. We may also send you a newsletter about our practice and the services we offer. You may contact our Privacy Officer to request that these materials not be sent to you.

Business Associates: We will share your protected health information with third party Business Associates that perform various activities for our practice. Whenever we disclose your protected health information to a business associate, we will have a written contract that that will protect the privacy of your protected health information.

Your Written Authorization Is Required For Other Uses Of Your Protected Health Information

Any other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization at any time, in writing, except to the extent that our office has already released your health information as provided for in your authorization.

Use and Disclosure Permitted Without Authorization But With An Opportunity To Object

Family Members and Friends: Unless you object, we may disclose to your family member, a relative, a close friend or any other person you select, your protected health information to the extent necessary to help with your dental care or with payment for the services we have provided. We will also use our professional judgment and common practice to make reasonable decisions in your best interest in allowing a person to pick up dental supplies, x-rays, prescriptions or other similar forms of health information.

Other Disclosures That May Be Made Without Your Authorization

Required By Law: We may use or disclose your protected 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 that of other persons.

Military Personnel and National Security: We may disclose the health information of Armed Forces personnel when requested by command military authorities. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence and other national security activities.

Worker’s Compensation & Health Oversight Activities: We may disclose your protected health information to comply with Worker’s Compensation Laws and to health oversight agencies when conducting investigations or inspections as authorized by law.

Required Uses and Disclosures: Under the law, we must make disclosures to you and when required, to the Department of Health and Human Services when determining our compliance.

You Have The Following Rights

Inspect and copy your protected health information. 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 practically do so. You must make the request in writing to obtain access to your health information. You may obtain access by sending a letter to our Privacy Officer listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses. If you prefer, we will prepare a summary or an explanation of your health information for a fee.

Request a restriction of your protected health information. 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.

Request alternative communications. 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 how payments will be handled under the alternative means or location you request.

Request an amendment your health information. You have the right to request that we amend or correct your health information. Your request must be in writing. The request must explain why the information should be amended or corrected. We may deny your request under certain situations.

Receive an accounting of disclosures we have made of your health information. You have the right to an accounting of disclosures of your health information that occurred after April 14, 2003. This accounting will be for purposes other than treatment, payment or healthcare operations, or disclosures we may have made to you, to family members or friends involved in your care. The right to receive this information is subject to some exceptions. If you request this accounting more than once in a 12 month period; we may charge you a reasonable, cost based fee.

Make a complaint about our privacy practices. If you are concerned that we have violated your privacy rights, you may file a complaint with our Privacy Officer using the contact information listed at the bottom of this page. You may also file a written complaint with the Department of Health and Human Services. We will provide you with their address upon request. We will not retaliate against you for making a complaint or change the way we treat you.

You may obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

Effective Date: March 1, 2013

Privacy Officer: Brittany Haught
Telephone: (678) 947-3600
12420 Cumming Hwy, Suite 306
Canton, GA 30115

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