Adult HHF (endicott)

OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. Protection of patient privacy is important to us. This notice summarizes the privacy practices that will be followed by our practice, We are 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 June 1st, 2020, 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 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.

USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment. For example, we may use or disclose your health information to another dentist, physician or other health care 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: Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. If you give us an 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.
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 other person involved in your treatment to the extent necessary to help with your healthcare.

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. Electronic Filing: We may submit insurance claims electronically through our practice software.
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 correctional institutions or law enforcement officials 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 email, text messages, voicemail messages, postcards or letters.

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 may also submit a written complaint with 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.

PATIENT RIGHTS
Access: You have the right to look at or get copies of your health information, with limited exceptions. Contact us using the information listed at the end of the 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 $0.40 for each page and $14.00 per hour for staff time to 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.
Disclosing Accounting: You may have the right to receive a list of instances in which your health information was disclosed for purposes other than treatment or certain other activities for the last 6 years, but not before January 1st, 2010. 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 these additional requests.
Alternative Communication: You may 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. We may agree to reasonable requests.
Amendment: You may 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 website or by e-mail, you are entitled to receive this Notice in written form.

PRIVACY AUTHORIZATION
This Authorization is required by the privacy regulations promulgated by the United States Department of Health and Human Services. Your Protected Health Information (PHI) will be used or disclosed for the purposes of: LECTURES, PUBLICATIONS, RESEARCH and/or PRACTICE MARKETING. This information will be disclosed to the following people: all employees of this office. You have the right to revoke this authorization at any time in writing. However, your revocation will not be effective to the extent that this authorization has been relied on. If your treatment will be used for research purposes, we may condition your treatment on obtaining this Authorization, in which case you may not receive treatment. The information used or disclosed per this Authorization may be subject to re-disclosure by the recipient(s), and thus, no longer protected by the privacy rules.

We are grateful that so many of our patients realize how important your appointment is to maintain good oral and overall health. We understand that sometimes things get in the way and appointments need to be canceled. We would like to take this opportunity to inform you of our policy on missed or rescheduled appointments.

You may cancel or reschedule an appointment with 24 hours advance notice with no extra charge. Any missed appointment or a cancel- ation with less than 24 hours' notice will be subject to a $50 fee. You can contact our office via phone or text at (918) 451-0211.
Keep in mind that regular cleanings are more than 'just a cleaning'. In addition to the cleaning, we evaluate your overall dental health including an oral cancer screening, an evaluation for decay and gum disease, among many other things. Research has shown a very strong link between dental health and your overall health. So, please remember to reschedule any missed appointment at your earliest convenience.

Our patients and their oral health are important to us. Please let us know how we can make it easier for you to maintain your regular dental hygiene appointments. To help our patients, we provide reminders of upcoming appointments by sending a reminder two to three weeks prior to the appointment, one week prior, and for patients that would like a reminder the day before their appointment, we provide that as well.
By signing this form, you agree that you understand that all charges for treatment are due and payable at the time services are rendered, unless prior arrangements have been made. By signing this form, you also agree to authorize insurance benefits to be paid directly to our practice.

You agree that insurance portions are ESTIMATED based on information released by your insurance company. However, the estimated amount of insurance is NOT a guarantee of payment. You are aware that insurance is a contract between yourself and your insurance carrier/provider. As a courtesy, claims may be filed on your behalf. If for some reason the insurance does not cover the benefit we have estimated, that difference will become the responsibility of the patient/parent/guardian.

You understand that you are financially responsible to the doctor(s) for all treatment. Returned checks will result in a $35.00 charge to your account. In that case, only cash or credit card payments will be accepted from that point forward.