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The Health Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPAA” provides penalties for covered entities that misuse personal health information.
As required by “HIPAA” we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.
We may use and disclose your medical records only for each of the following purposes: treatment, payment, and health care operations.
We may also create and distribute de-identified health information by removing all references to individually identifiable information.
We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.
You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:
7112 I agree to be responsible for all charges for dental services and materials not paid by my dental plan, unless prohibited by law, or unless Esthetix Dental Spa, has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to the use and disclosure of my protected health information (PHI) to carry out payment activities in connection with any and all claims.
I hereby authorize and direct payment of dental benefits otherwise payable to me, directly to:
Esthetix Dental Spa
285 Fort Worth Washington Ave
New York, NY 10032
If you find information in your record to be incorrect, you may ask the record be corrected by writing to the above address.
By my initialing above, I acknowledge that I have read, been given the opportunity to read, and/or have been provided a copy of Esthetix Dental Spa notice of Privacy Practices.
We cooperate fully with our patients who are covered by insurance plans. We expect insured patients to read their policies carefully. It is very important that you are familiar with its benefits and limitations. We will accept assignment of benefits provided the necessary documentation has been provided. We do require that you pay your deductible and/or estimated co-pay at the time of service. If your insurance company has not paid your account in full within 45 days of treatment or denies you can claim for ANY reason, you are responsible for the total balance.
All estimates given for proposed treatment are not a guarantee of benefits. The office does not allow the insurance company to dictate recommended treatment. All prosthetic services must be paid in full on or before completion. We reserve the right to charge any account balance due over 30 days at 1.5% monthly finance charge or a $5.00 repeat billing charge, whichever is greater. You are responsible for any and all collection cost and/or fees associated with collecting the balance of your account. We consider the parent or guardian who brings the child to our office for treatment the responsible party for payment of the child’s account. If someone else is legally responsible for the child’s account, it remains the responsibility of the parent or guardian bringing the child for treatment to seek reimbursement for payment made to our office. We will be happy to assist you by providing you a copy of the charges and payments made at each visit. The office reserves the right to charge $50.00 PER HALF HOUR of a broken appointment up to the entire cost of treatment if not cancelled within the 48 hours. To avoid a charge, 48 hours notice must be given. Treatment plans signed and paid for must be cancelled within 48 hours for a refund minus 15% administrative fee. A $35.00 fee will be added to your account for any checks returned to us by the bank. A $25.00 fee will be assessed for the duplication of records/x-rays.
