In an effort to reduce costs, increase efficiency and maintain the highest level of professional care, we have established a financial policy that both patients and office personnel must adhere to. Our Office Financial Policy is as follows: I. We accept payment by CASH and MOST MAJOR CREDIT CARDS. II. As a courtesy, we will accept most insurances. and will gladly process your claim - however any estimated deductibles, co-payments, and secondary coverages will be due in full at time of visit. III. If you are covered under multiple Insurance Plans, you are required to provide all policy information at the time of your appointment. This allows us to coordinate your benefits and file your claims accurately. Failure to do so may result in the denial of your claim payment and you will be responsible for the associated fees. IV. Although our office will process your insurance claims, please understand it is your responsibility to satisfy any account balance in full for all services rendered. If you have any questions regarding these financial policies, please do not hesitate to speak to our office personnel. We are here to help you in every way. PLEASE ACKNOWLEDGE THAT YOU UNDERSTAND THE ABOVE POLICIES

I hereby authorize the doctor to perform any forms of treatment, medication, and therapy, which may be deemed necessary. I also understand that before treatment, the doctor and/or staff will give me full explanation of the procedure(s) involved. I agree to pay for services rendered by this dental practice.

Federal law requires that this notice, which describes how health information about you may be used and disclosed and how you can access this information, presents the information that federal law requires us to give our patients. We must provide this notice to each patient no later than the date of our first service delivery to the patient, including service delivered electronically. The law requires that we make a good-faith attempt to obtain written acknowledgement of receipt of this notice from the patient. The law also requires that we provide copies of this notice to any patient who request it and post the notice in our office in a clear and prominent location. Whenever this notice is revised, we must make it available upon request on or after the effective date of the revision in a manner consistent with the above instructions. This notice went into effect March 1, 2003, and will remain in effect until replaced.

We do, however, 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 that 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 this notice at any time. For more information about our privacy practices, or for additional copies, please contact us using the information listed at the end of this notice.

We use and disclose health information about you for treatment, payment and healthcare operations.
- Treatment: We may use or disclose your health information to a dental specialist or other healthcare 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 assessments 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: In addition to our use of your health information for treatment, payment, or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. 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. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in the Notice.
- 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 to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
- Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgement and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
- 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.
- 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 institution or law enforcement officials having lawful custody of protected health information of an inmate or patient under certain circumstances.
- Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).


We do, however, 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 that 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 this notice at any time. For more information about our privacy practices, or for additional copies, please contact us using the information listed at the end of this notice.