Spirit Lake Family Dental Notice of Privacy Practices

STATEMENT OF PRIVACY PRACTICES

The staff of Spirit Lake Family Dental is dedicated to protecting the privacy rights of our patients and the confidential information entrusted to us.  The commitment of each employee to ensure that your health information is never compromised is a principle concept of our practice.  We may, from time to time, amend our privacy policies and practices.  A current copy will always be available for your review at our office.

PROTECTING YOUR PERSONAL HEALTHCARE INFORMATION

We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and Accountability Act and the state of Idaho.  This includes relating to your treatment, payment, and our dental care operations.  Your personal health information will never be otherwise given to anyone – even family members – without your written consent.  You, of course, may give written authorization for us to disclose your information to anyone you choose, for any purposes.

COLLECTING PROTECTED HEALTH INFORMATION

We will only request personal information needed to provide our standard of quality dental care, implement payment activities, conduct normal dental practice operations, and comply with the law.  This may include your name, address, telephone number(s), Social Security Number, employment data, medical history, health records, etc.  While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary.  Regardless of the source, your personal information will always be protected to the full extent of the law.

DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION

As stated above, we may disclose information as required by law.  We are obligated to provide information to law enforcement and governmental officials under certain circumstances.  We will not use your information for marketing purposes without your written consent.  We may use and/or disclose your health information to communicate reminders about your appointments including voicemail messages, text messages, email messages, answering machines, and postcards.

PATIENT RIGHTS

You have the right to request copies of your healthcare information; to request copies in a variety of formats; and to request a list of instances in which we, or business associates, have disclosed your protected information for uses other than stated above.  All such requests must be in writing.  We may charge for your copies in an amount allowed by law.  If you believe your rights have been violated, we urge you to notify us immediately.  You can also notify the US Department of Health and Human Services.  Please let us know if you have any question concerning your privacy right and the protection of your personal health information.

We believe in the importance of quality dental care, and we strive to provide the best dental treatment possible.  Also, we understand the financial limitations that can influence your choice of care. We work with most insurance companies and always try to maximize your coverage through meticulous detailing of procedures and interaction with your insurer.  We fill out your claim forms and are available to answer any questions we can.

Financial and Billing Policies

If you have insurance:

• We will gladly bill your insurance on your behalf, so please bring all necessary information with you. This includes your insurance card and subscriber information.
• If your insurance requires Co-Payment, it is due at time of service.
• Even if you have insurance, your patient portion is your responsibility and due at the time of service.
• There will be a $25 late fee for all patient balances over 30 days.
• We will provide ESTIMATES for your treatment as a courtesy to you. However, all insurances and plans are unique, and ultimately YOU ARE RESPONSIBLE FOR KNOWING YOUR DENTAL INSURANCE BENEFITS.
• Your insurance company may downgrade fillings to amalgam fees for posterior teeth.  Dr. DeVore does not place amalgam. You are responsible for the difference.

If you DO NOT have insurance:

• We accept cash, personal checks, most major credit cards and Care Credit. Payment is due on date of service.

*There is a $35.00 charge for returned checks.

• Ask us about our in-house discount program.

*PARENTS OR LEGAL GUARDIANS MUST ACCOMPANY MINORS AND ARE RESPONSIBLE FOR PAYMENTS.*

Patient Late Cancellation and Failed Appointment Policy

• We confirm via emails, texts and phone calls. You may opt out of any of these services, just let us know.
• 24 hour notice for cancellations or rescheduling of appointments required.
• ALL LATE CANCELLATIONS/FAILED APPOINTMENTS WILL RESULT IN A $75.00 FEE CHARGED TO THE ACCOUNT.

My signature below verifies that I have read and received a copy (if requested) of the above financial policy. I understand that regardless of insurance coverage, I am responsible for payment on my account.

Patient Consent for Use and Disclosure of Protected Health Information/Privacy Practices

I acknowledge that I have reviewed or received a copy of the Notice of Privacy Practices for the office of Spirit Lake Family Dental. The notice describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office dental care operations, including communications with referring dentists.