INSURANCE DENTAL AND MEDICAL FORM

I understand that I am financially responsible for any charges not covered by my benefits. It is my responsibility to notify office of any changes to my benefits. In some cases, exact insurance benefits cannot be determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill if the submitted claims or any part of them are denied for payment. I understand that by signing this form I am accepting financial responsibility as explained above for all payment for products and services received. I authorize office to submit insurance claims on my behalf and to release information necessary to my insurance company for the processing of those claims. I assign all dental benefits for services rendered and authorize and direct my insurance carrier(s) to issue payment directly to office. I certify that the information I have provided is accurate to the best of my knowledge.

21 st Century Dental Care, P.C.
413 King George Road, Suite 201
Basking Ridge, NJ 07920
(908) 604-5959

II. HOW WE MAY USE AND DISCLOSE YOUR PHI.

We will use and disclose your PHI for many different reasons. For some of these uses or disclosures, we will need your prior authorization; for others, however, we do not. Listed below are the different categories of our uses and disclosures along with some examples of each category.
 
A. Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written Consent. We can use and disclose your PHI without your consent for the following reasons:

1. For treatment. We can disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are involved in your care. For example, if youre being treated by a physician, we can disclose your PHI to your physician in order to coordinate your care.
2. To obtain payment for treatment. We can use and disclose your PHI to bill and collect payment for the treatment and services provided by us to you. For example, we might send your PHI to your insurance company or health plan to get paid for the health care services that we have provided to you. We may also provide your PHI to our business associates, such as billing companies, claims processing companies, and others that process our health care claims.
3. For health care operations. We can disclose your PHI to operate our practice. For example, we might use your PHI to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who provided such services to you. We may also provide your PHI to our accountants, attorneys, consultants, and others to make sure we recomplying with applicable laws.
4. Other disclosures. We may also disclose your PHI to others without your consent in certain situations. For example, your consent isn't required if you need emergency treatment, as long as we try to get your consent after treatment is rendered, or if we try to get your consent but you are unable to communicate with us (for example, if you are unconscious or in severe pain) and we think that you would consent to such treatment if you were able to do so.

B. Certain Uses and Disclosures Do Not Require Your Consent. We can use and disclose your PHI without your consent or authorization for the following reasons:

1. When disclosure is required by federal, state or Iocal law; judicial or administrative proceedings; or, law enforcement. For example, we may make a disclosure to applicable officials when a law requires us to report information to government agencies and law enforcement personnel about victims of abuse or neglect; or when ordered in a judicial or administrative proceeding.
2. For public health activities. For example, we may have to report information about you to the county coroner.
3. For health oversight activities. For example, we may have to provide information to assist the government when it conducts an investigation or inspection of a health care provider or organization.
4. For research purposes. In certain circumstances, we may provide PHI in order to conduct medical research.
5. To avoid harm. In order to avoid a serious threat to the PHI to law enforcement personnel or persons able to prevent or lessen such harm.
6. For specific government functions. we may disclose PHI of military personnel and veterans in certain situations. And we may disclose PHI for national security purposes, such as protecting the President of the United States or conducting intelligence operations.
7. For workers compensation purposes. We may provide PHI in order to comply with workers compensation laws.
8. Appointment reminders and health related benefits or services. We may use PHI to provide appointment reminders or give you information about treatment alternatives, or other health care services or benefits we offer.

C. Certain Uses and Disclosures Require You to Have the Opportunity to Object.

1.  Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

D. Other Uses and Disclosures Require Your Prior Written Authorization. In any other situation not described in sections III A, B, and C above, we will ask for your written authorization before using or disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke such authorization in writing to stop any future uses and disclosures (to the extent that we havent taken any action in reliance on such authorization) of your PHI by me.

III. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI

A. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask that we limit how we use and disclose your PHI. We will consider your request, but we are not legally required to accept it. If we accept your request, we will put any limits in writing and abide by them except in emergency situations. You may not limit the uses and disclosures that we are legally required or allowed to make.
 
B. The Right to Choose How We Send PHI to You. You have the right to ask that we send information to you to at an alternate address (for example, sending information to your work address rather than your home address) or by alternate means (for example, e-mail instead of regular mail). We must agree to your request so long as we can easily provide the PHI to you in the format you requested.
 
C. The Right to See and Get Copies of Your PHI. In most cases, you have the right to look at or get copies of your PHI that we have, but you must make the request in writing. If we dont have your PHI but we know who does, we will tell you how to get it. We will respond to you within 30 days of receiving your written request. In certain situations, we may deny your request. If we do, we will tell you, in writing, our reasons for the denial and explain your right to have our denial reviewed. If you request copies of your PHI, we will charge you $.75 for each page, $10.00 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. Instead of providing the PHI you requested, we may provide you with a summary or explanation of the PHI as long as you agree to that and to the cost in advance.
 
D. The Right to Get a List of the Disclosures We Have Made. You have the right to get a list of instances in which we have disclosed your PHI. The list will not include uses or disclosures that you have already consented to, such as those made for treatment, payment, or health care operations, directly to you, or to your family. The list also won't include uses and disclosures made for national security purposes, to corrections or law enforcement personnel, or disclosures made before April 15, 2003. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you a reasonable cost based fee for each additional request.
 
E. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI or that a piece of important information is missing, you have the right to request that we correct the existing information or add the missing information. You must provide the request and your reason for the request in writing. We will respond within 60 days of receiving your request to correct or update your PHI. We may deny your request in writing if the PHI is (i) correct and complete, (ii) not created by us, (iii) not allowed to be disclosed, or (iv) not part of our records. Our written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you don't file one, you have the right to request that your request and our denial be attached to all future disclosures of your PHI. If we approve your request, we will make the change to your PHI, tell you that we have done it, and tell others that need to know about the change to your PHI.
 
F. The Right to Get This Notice by E-Mail. You have the right to get a copy of this notice by e-mail. Even if you have agreed to receive notice via e-mail, you also have the right to request a paper copy of it.

IV. HOW TO COMPLAIN ABOUT OUR PRIVACY PRACTICES
 
If you think that we may have violated your privacy rights, or you disagree with a decision we made about access to your PHI, you may file a complaint with the person listed in Section III below. You also may send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W., Washington, D.C. 20201. We will take no retaliatory action against you if you file a complaint about our privacy practices.
 
V. PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT OUR PRIVACY PRACTICES
 
If you have any questions about this notice or any complaints about our privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact us at: Dr. Vitaly Friedman, 413 King George Road, Suite 201, Basking Ridge, NJ 07920. (908) 604-5959.
 
VI. EFFECTIVE DATE OF THIS NOTICE
 
This notice went into effect on April 14, 2003.

21 st Century Dental Care, P.C.
413 King George Road, Suite 201
Basking Ridge, NJ 07920
(908) 604-5959

I [Fname] [Lname] have been presented with the Notice of Privacy Policy of 21 st Century Dental Care, P.C.

 (initial here) I hereby acknowledge that I have been given the opportunity to review the policy and receive a paper copy.

Thank you for choosing 21 st Century Dental Care, P.C. as your health care provider. We are committed to your treatment being successful. The following is a statement of our Financial Policy, which we require you to read and sign prior to any treatment. Please understand that this financial policy is enforced to keep costs at a reasonable level, thus preventing frequent fee increases.

FULL PAYMENT IS DUE AT THE TIME OF SERVICE. WE ACCEPT CASH, CHECKS, AND ALL MAJOR CREDIT CARDS.

INSURANCE: We may accept assignment of primary insurance benefits; however, we do require deductibles and co-payments be paid at the time of service. The balance is your responsibility. Your insurance policy is a contract between you and your insurance company; we are not a party to that contract nor are we responsible for procedures that are not covered for any reason. We must have complete and up to date insurance information in order to bill your insurance company on your behalf. In the event that your insurance company has not paid their portion within 45 days, the balance will become your responsibility.

USUAL AND CUSTOMARY RATES: Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary fro our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary fees.

MINOR PATIENTS: The parents or guardians accompanying a minor are responsible for the full payment. For unaccompanied minors, non-emergency treatment will be denied unless charges have been preauthorized to a credit card or payment by cash or check at the time of service.

FINANCE CHARGES: A finance charge will be billed to any account in which the balance remains unpaid for 30 days without payment arrangements. This monthly fee will equal 18% APR from the date the payment was due.

COLLECTION FEES: When an account becomes 60 days past due, collection action may be taken outside of 21 st Century Dental Care, P.C. In this event, you will be responsible for all collection and legal fees, which may equal 50% of the total balance plus legal fees.

MISSED APPOINTMENTS: Unless cancelled at least 24 hours in advance, our policy is to charge for missed appointments at the rate of a normal office visit. Please help us to serve you more efficiently by keeping scheduled appointments.

RETURNED CHECKS: If a check is returned NSF, there will be a $35.00 charge and, from that point on, checks will not be accepted.

I, the undersigned, assume financial responsibility as stated above and responsibility for all collection and legal fees if my account becomes past due. I have read, understand, and agree to this Financial Policy.