New Patient Forms (English) - Rochester

GENTLE DENTAL CARE OF ROCHESTER PC
Patient Rules
1. All Forms and letters require 1 week to complete. This includes school forms,
dental records, copy of x-rays, prior authorization request, referrals, and official
letters.
2. Please bring in a current list of health conditions, previous and future surgeries,
and all prescription and over the counter medications that you are taking.
3. Please bring in your current insurance card and photo ID with you to each
appointment. If you have any changes on your insurance please come 15 minutes
prior to your appointment time to complete necessary paperwork.
4. Please give us 24 hours notice during business hours if you will not be attending
your scheduled appointment. We reserve the right to not reschedule any more
appointments if you have missed 3 appointments without a 24 hours cancellation.
5. Please show up for your appointment on time. This will ensure that all patients are
seen in a timely manner. If you ever choose to arrive early for an appointment, we
cannot guarantee you will be seen early. If you are going to be late for your
appointment, please call the office to notify us. If you arrive late, you will be seen
in the order that you arrived. If you are 15 minutes late to your appointment this
will count as a missed appointment, and we will reschedule your appointment as
soon as possible.
6. Our providers attempt to address any concerns that you may have at the time of
your appointment. Please be patient when your provider is running behind. Also
know that you will be given the same attention.
7. Please make that line when checking in or out, this will insure the privacy of all
our patients. Have all co-payments ready when checking in.
8. When you’re at the office or calling the office, we promise to speak to you with
respect and courtesy. Therefore, we ask that you speak respectfully and with
courtesy to our staff! Cursing and threatening tones will not be tolerated and will
result in a permanent dismissal from the practice. Any personal conflicts should
be addressed with the office manager by filling out the necessary forms prior to
discussion.
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9. While in waiting room, please keep cell phone conversations/game use at a
reasonable volume, or please step outside if not possible. Once you are called for
treatment cell phones should be put on silent or vibrate. No calls, video, or
pictures are allowed during or in treatment, if discovered that this is violated you
will be permanently dismissed from the office. If you are expecting an emergency
call, please notify an assistant, and we can reschedule this appointment if needed.
10. When entering the lobby no food or drink will be allowed. If you or your parents
must leave to eat, please notify a secretary before leaving the office.
11. No children under the age 15 years old can be left unattended in waiting room
without being accompanied by an adult. If you come to your appointment without
another adult to supervise your child/children, you will have to reschedule your
appointment.
12. If you have an appointment and you need to step outside before you are called, for
example a phone call, smoke, eat, etc., please notify the front desk before leaving,
if failed to do so and you are called, this will result as a missed appointment.
Please sign below to indicate that you have read and fully understand our policies.
_________________
Date
____________________________________________________
Patient Signature
Thank you for your compliance with our patient rules. By following these guidelines
we will be able to serve all of our patients efficiently and provide the best patient
care.
_____________________________________________________________
_____________________________________________________________
ePrescriptions
Pharmacy Name:
Address:
Phone:
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Gentle Dental Care of Rochester PC
Financial Policy
All payment is due at time of service unless prior arrangements have been made.
1.
Payment is required at the time services are rendered unless other arrangements have been made in advance. This
includes applicable coinsurance and co-payments for participating insurance companies. Our insurance contracts
do not allow us to waive co-payments. A $15.00 processing fee will be add to your balance if payment is not
cover the day of service.
2.
We accepts cash, money orders, VISA, MasterCard, Discover, American Express and
Care Credit Payments.
3.
All returned checks will be assessed a $30.00 service fee.
4.
Patients with a balance 30 days or more overdue must make arrangements for payment prior to scheduling
appointments. Accounts showing no progress for 60 days will be sent to a collections agency and you will be
responsible for any added agency or legal charges.
5.
You are responsible to inform us of updated and accurate insurance information for us to properly bill insurance
on your behalf. Insurance information must be updated for each patient in the family as each patient has a separate
account.
6.
We bill participating insurance companies as a courtesy to you. You are required to pay your co-payments at the
time of service. If we have not received payment from your insurance company within 45 days of the date of
service, you may be expected to pay the balance in full. You are responsible to be sure all charges are paid,
whether by you or by your insurance carrier.
7.
Patients not covered by insurance are considered “self pay” and are required to make a full payment on their
account at the time of service unless other arrangements have been made.
8.
Broken appointments represent a cost to us, to you and to to other patients who could have been seen in the time
set aside for you. Cancellations are requested 24 hours prior to the appointment (a Monday appointment would
have to be changed by Friday) or there will be a thirty dollar ($30.00) charge . Three(3) or more missed
appointments without at least twenty four (24) hours notice to our staff may result in discharge from the practice.
Please sign below to indicate that you have read and fully understand our policy.
______________________
Date
_______________________
Social Security
______________________________________
Full Name of patient or Responsable
______________________________________
Signature
GENTLE DENTAL CARE OF ROCHESTER PC
AUTHORIZATION OF USE AND DISCLOSURE
OF PROTECTED HEALTH INFORMATION.
I was given the opportunity to review the Gentle Dental Care of Rochester, PC HIPAA Notice of Privacy
Practices.
I ____________________________________authorize Gentle Dental Care of Rochester, PC
to communicate information to me regarding appointments, medications, approvals, referrals, and
treatment plan by leaving a message on the answering machine/voicemail at the following
telephone number(s):
Home #: _____________________________Cell phone #: ________________________
Email: __________________________________________________________________
Signature ___________________________________________ Date______________________
I authorize Gentle Dental Care of Rochester, PC to disclose the following information:
___Medications ___Appointments
___Approvals
___Treatment Plan
____Only the following information
______________________________________________________________________________
______________________________________________________________________________
To the following individual(s):
Name_________________________________________ Relationship______________________
Telephone______________________________________________________________________
Name_________________________________________ Relationship______________________
Telephone______________________________________________________________________
Name_________________________________________ Relationship______________________
Telephone______________________________________________________________________
This authorization is effective through ___/___/___ unless revoked or terminated by the patient or patients
representative. You may revoke or terminate this authorization by submitting a written revocation to our
office.
The privacy of this information may not be protected under the federal privacy regulations if disclosed by
individuals listed above.
Print Name ______________________________________________________ DOB___/___/___
Signature _______________________________________________________ Date ___/___/___
Signature of Representative/Guardian________________________________________________
Relationship with patient _________________________________________________________
GENTLE DENTAL CARE OF ROCHESTER
Acknowledgement of Receipt of Notice of Privacy Practices
Patient Name: ________________________________________
Patient ID #: _______________________
I hereby acknowledge that I have received a copy of Gentle Dental Care of Rochester PC’s Notice of Privacy
Practices. I understand that I have the right to refuse to sign this acknowledgement if I so choose.
____________________________________________________
Signature of Patient or Legal Representative
__________________________________
Date
Relationship to Patient (if applicable)
____________________________________________________
Printed Name of Patient’s Representative (if applicable)
Parent or guardian of unemancipated minor
Court appointed guardian
Executor or administrator of decedent's estate
Power of Attorney
------------------------------------------------------------------------------------FOR OFFICE USE ONLY
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices on the following date,
_____________________________ but acknowledgment could not be obtained because:
Patient/representative refused to sign
Emergency situation prevented us from obtaining acknowledgement at this time
(will attempt again at a later date)
Communication barriers prohibited obtaining acknowledgement (Explain)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Other (Specify)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
© Copyright 2002-2013, HIPAATraining.com
GENTLE DENTAL CARE OF ROCHESTER PC
NOTICE OF PRIVACY PRACTICES
EFFECTIVE DATE: __09/01/2013_________________
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
UNDERSTANDING YOUR HEALTH RECORD/INFORMATION
Each time you visit a hospital, physician, dentist, or other healthcare provider, a record of your visit is
made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment,
and a plan for future care or treatment. This information often referred to as your health or medical record,
serves as a basis for planning your care and treatment and serves as a means of communication among the
many health professionals who contribute to your care. Understanding what is in your record and how
your health information is used helps you to ensure its accuracy, better understand who, what, when, where,
and why others may access your health information, and helps you make more informed decisions when
authorizing disclosure to others.
YOUR HEALTH INFORMATION RIGHTS
Unless otherwise required by law, your health record is the physical property of the healthcare practitioner
or facility that compiled it. However, you have certain rights with respect to the information. You have the
right to:
1.
Receive a copy of this Notice of Privacy Practices from us upon enrollment or upon request.
2.
Request restrictions on our uses and disclosures of your protected health information for
treatment, payment and health care operations. This includes your right to request that we not disclose your
health information to a health plan for payment or health care operations if you have paid in full and out of
pocket for the services provided. We reserve the right not to agree to a given requested restriction.
3.
Request to receive communications of protected health information in confidence.
4.
Inspect and obtain a copy of the protected health information contained in your medical and
billing records and in any other Practice records used by us to make decisions about you. If we maintain or
use electronic health records, you will also have the right to obtain a copy or forward a copy of your
electronic health record to a third party. A reasonable copying/labor charge may apply.
5.
Request an amendment to your protected health information. However, we may deny your
request for an amendment, if we determine that the protected health information or record that is the subject
of the request:
•
was not created by us, unless you provide a reasonable basis to believe that the originator of the
protected health information is no longer available to act on the requested amendment;
•
is not part of your medical or billing records;
•
is not available for inspection as set forth above; or
•
is accurate and complete.
In any event, any agreed upon amendment will be included as an addition to, and not a replacement of,
already existing records.
6.
Receive an accounting of disclosures of protected health information made by us to individuals
or entities other than to you, except for disclosures:
•
to carry out treatment, payment and health care operations as provided above;
•
to persons involved in your care or for other notification purposes as provided by law;
•
to correctional institutions or law enforcement officials as provided by law;
•
for national security or intelligence purposes;
•
that occurred prior to the date of compliance with privacy standards (April 14, 2003);
•
incidental to other permissible uses or disclosures;
•
that are part of a limited data set (does not contain protected health information that directly
identifies individuals);
•
made to patient or their personal representatives;
•
for which a written authorization form from the patient has been received
7.
Revoke your authorization to use or disclose health information except to the extent that we have
already been taken action in reliance on your authorization, or if the authorization was obtained as a condition
of obtaining insurance coverage and other applicable law provides the insurer that obtained the authorization
with the right to contest a claim under the policy.
8.
Receive notification if affected by a breach of unsecured PHI
© Copyright 2002-2013, HIPAATraining.com
HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
This organization may use and/or disclose your medical information for the following purposes:
Treatment: We may use and disclose protected health
information in the provision, coordination, or management of your
health care, including consultations between health care providers
regarding your care and referrals for health care from one health
care provider to another.
Payment: We may use and disclose protected health information
to obtain reimbursement for the health care provided to you,
including determinations of eligibility and coverage and other
utilization review activities.
Regular Healthcare Operations: We may use and disclose
protected health information to support functions of our practice
related to treatment and payment, such as quality assurance
activities, case management, receiving and responding to patient
complaints, physician reviews, compliance programs, audits,
business planning, development, management and administrative
activities.
Appointment Reminders: We may use and disclose protected
health information to contact you to provide appointment
reminders.
Treatment Alternatives: We may use and disclose protected
health information to tell you about or recommend possible
treatment alternatives or other health related benefits and services
that may be of interest to you
Health-Related Benefits and Services: We may use and disclose
protected health information to tell you about health-related
benefits, services, or medical education classes that may be of
interest to you.
Individuals Involved in Your Care or Payment for Your Care:
Unless you object, we may disclose your protected health
information to your family or friends or any other individual
identified by you when they are involved in your care or the
payment for your care. We will only disclose the protected health
information directly relevant to their involvement in your care or
payment. We may also disclose your protected health information
to notify a person responsible for your care (or to identify such
person) of your location, general condition or death.
Business Associates: There may be some services provided in our
organization through contracts with Business Associates.
Examples include physician services in the emergency department
and radiology, certain laboratory tests, and a copy service we use
when making copies of your health record. When these services
are contracted, we may disclose some or all of your health
information to our Business Associate so that they can perform the
job we have asked them to do. To protect your health information,
however, we require the Business Associate to appropriately
safeguard your information.
Organ and Tissue Donation: If you are an organ donor, we may
release medical information to organizations that handle organ
procurement or organ, eye or tissue transplantation or to an organ
donation bank, as necessary to facilitate organ or tissue donation
and transplantation.
Worker's Compensation: We may release protected health
information about you for programs that provide benefits for work
related injuries or illness.
Communicable Diseases: We may disclose protected health
information to notify a person who may have been exposed to a
disease or may be at risk for contracting or spreading a disease or
condition.
Health Oversight Activities: We may disclose protected health
information to federal or state agencies that oversee our activities.
Law Enforcement: We may disclose protected health information
as required by law or in response to a valid judge ordered subpoena.
For example in cases of victims of abuse or domestic violence; to
identify or locate a suspect, fugitive, material witness, or missing
person; related to judicial or administrative proceedings; or related to
other law enforcement purposes.
Military and Veterans: If you are a member of the armed forces,
we may release protected health information about you as required
by military command authorities.
Lawsuits and Disputes: We may disclose protected health
information about you in response to a court or administrative order.
We may also disclose medical information about you in response to a
subpoena, discovery request, or other lawful process.
Inmates: If you are an inmate of a correctional institution or under
the custody of a law enforcement official, we may release protected
health information about you to the correctional institution or law
enforcement official. An inmate does not have the right to the
Notice of Privacy Practices.
Abuse or Neglect: We may disclose protected health information to
notify the appropriate government authority if we believe a patient
has been the victim of abuse, neglect or domestic violence. We will
only make this disclosure if you agree or when required or
authorized by law.
Fund raising: Unless you notify us you object, we may contact you
as part of a fund raising effort for our practice. You may opt out of
receiving fund raising materials by notifying the practice’s privacy
officer at any time at the telephone number or the address at the end
of this document. This will also be documented and described in any
fund raising material you receive.
Coroners, Medical Examiners, and Funeral Directors: We may
release protected health information to a coroner or medical
examiner. This may be necessary to identify a deceased person or
determine the cause of death. We may also release protected health
information about patients to funeral directors as necessary to carry
out their duties.
Public Health Risks: We may disclose your protected health
information for public health activities and purposes to a public
health authority that is permitted by law to collect or receive the
information. The disclosure will be made for the purpose such as
controlling disease, injury or disability.
Serious Threats: As permitted by applicable law and standards of
ethical conduct, we may use and disclose protected health
information if we, in good faith, believe that the use or disclosure is
necessary to prevent or lessen a serious and imminent threat to the
health or safety of a person or the public.
Food and Drug Administration (FDA): As required by law, we
may disclose to the FDA health information relative to adverse
events with respect to food, supplements, product and product
defects, or post marketing surveillance information to enable product
recalls, repairs, or replacement.
Research (inpatient): We may disclose information to researchers
when an institutional review board that has reviewed the research
proposal and established protocols to ensure the privacy of your
health information has approved their research.
© Copyright 2002-2013, HIPAATraining.com
OUR RESPONSIBILITIES
We are required to maintain the privacy of your health information. In addition, we are required to provide
you with a notice of our legal duties and privacy practices with respect to information we collect and
maintain about you. We must abide by the terms of this notice. We reserve the right to change our
practices and to make the new provisions effective for all the protected health information we maintain. If
our information practices change, a revised notice will be mailed to the address you have supplied upon
request. If we maintain a Web site that provides information about our patient/customer services or
benefits, the new notice will be posted on that Web site.
Your health information will not be used or disclosed without your written authorization, except as
described in this notice. The following uses and disclosures will be made only with explicit authorization
from you: (i) uses and disclosures of your health information for marketing purposes, including subsidized
treatment communications; (ii) disclosures that constitute a sale of your health information; and (iii) other
uses and disclosures not described in the notice. Except as noted above, you may revoke your authorization
in writing at any time.
FOR MORE INFORMATION OR TO REPORT A PROBLEM
If you have questions about this notice or would like additional information, you may contact our Privacy
Officer, INGRID APONTE, at the telephone or address below. If you believe that your privacy rights
have been violated, you have the right to file a complaint with the Privacy Officer at GENTLE DENTAL
CARE OF ROCHESTER or with the Secretary of the Department of Health and Human Services. The
complaint must be in writing, describe the acts or omissions that you believe violate your privacy rights,
and be filed within 180 days of when you knew or should have known that the act or omission occurred.
We will take no retaliatory action against you if you make such complaints.
The contact information for both is included below.
U.S. Department of Health and Human Services
Office of the Secretary
200 Independence Avenue, S.W.
Washington, D.C. 20201
Tel: (202) 619-0257
Toll Free: 1-877-696-6775
http://www.hhs.gov/contacts
GENTLE DENTAL CARE OF ROCHESTER PC
INGRID APONTE
Privacy Officer
295 Monroe Avenue, Rochester NY 14607
Tel: 585-467-4513
Fax: 585-467-4665
admin@rochestergentledentalpc.com
NOTICE OF PRIVACY PRACTICES AVAILABILITY
This notice will be prominently posted in the office where registration occurs. You will be provided a hard
copy; at the time we first deliver services to you. Thereafter, you may obtain a copy upon request, and the
notice will be maintained on the organization’s Web site for downloading.
© Copyright 2002-2013, HIPAATraining.com