Forms

We would like to welcome you to our dental practice and explain our financial policy. We believe that service to our patients is best when there is complete understanding and mutual cooperation.

Our patients can expect from us:

1. A high degree of professional skill and ability.
2. A team that will perform all services to the best of our ability and knowledge.
3. A complete explanation of the findings that result from a thorough examination and diagnosis. We will discuss all fees prior to the start of treatment.

In return, we expect from our patients:

1. Cooperation in making and keeping appointments.
2. A conscientious effort to follow home care and oral hygiene instructions.
3. Follow recommended recall interval, based on your needs.
4. A definite arrangement for payment of fees.

Payment is due at the time services are rendered regardless of your insurance coverage. We accept personal check, cash, Visa and master card. If you are looking for a monthly payment arrangement, we offer Cherry Financing and Care Credit in our office. Both are third party credit administrators and you must apply for credit.

A 4.2% FEE WILL BE ADDED TO CREDIT CARD TRANSACTIONS.

ALL SAME DAY CANCELLATIONS AND NO-SHOW APPOINTMENTS ARE SUBJECT TO A $29.00 FEE.

If you do not have insurance, please be prepared to fully cover the fees for each visit.

If you have insurance, we will process your insurance as a courtesy to you. The amount estimated not covered by insurance is due the day services are rendered. We will give you a treatment estimate that will show your payment due. It is your responsibility to review your monthly statement to make sure your insurance company has paid. It generally takes four to six weeks to receive the insurance payment. Please call us if you have any questions.

When crowns, bridges, implants, partial or complete dentures are needed, we ask that you pay half of the financial responsibility at the first appointment and the remaining balance on the final appointment.

We want you to receive the best dentistry and we want to make it affordable. If you need help prioritizing your dental treatment, please let us know.

I agree I am fully responsible for the total payment of all procedures in this office, this includes treatment that is not a benefit of my dental insurance. I authorize release of all financial data. Returned checks will be subject to a $29 fee. Any balances carried over 30 days from final insurance payment will be subject to a 1.5% per month finance charge ($3.00 minimum)

**You May Refuse to Sign This Acknowledgment**

If the patient is less than 18 years of age, a parent, or legal guardian must Sign.

As required by the Privacy Regulations, I hereby acknowledge that a current copy of 5 Mile Smiles “NOTICE OF PRIVACY PRACTICES” has been made available to me and has been explained to me to my satisfaction.

As required by the Privacy Regulations, i am aware that this practice has included a provision that it reserves the right to change the terms of its notice and to make the new notice provisions effective for all protected health information that it maintains.

I understand that this office may change their Notice of Privacy Practices and is not required to honor the terms of the original/previous versions.

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW You can GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY: We are required by applicable federal and state law to maintain the privacy of your health information. We are also 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 April 14, 2003, 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 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.

For more information about our privacy practices, or to request a copy of our Notice, please contact us using the information listed on this website.

USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician 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 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: 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 't 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 this 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 genera} condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity zo 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 judgment 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 writes 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, domestic violence, or the possible victim of other crimes. We may disclose your health information to the extent necessary to aver 3 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 official’s health information required for lawful intelligence, counterintelligence and other national security activities. We may disclose to correctional institution or law enforcement official 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 voicemail messages, postcards, or letters).

PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information, with limited exceptions. You May nee You must Provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do So. You must make A request in writing to obtain access to your health information. We may charge you a reasonable cost-based fee for expenses such as copies and staff time. If you request an alternative format, we will charge a cost-based fee for providing your health informatic in that format.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations, and certain other activities, but not before April 1, 2003. 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.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement, except in an emergency.

Alternative Communication: You have the right to 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 satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to 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 electronic mail (e-mail), you are entitled to receive this Notice in written form.

QUESTIONS AND COMPLAINTS If you want more information about our privacy practices or have questions or concerns, please contact us at the address or phone number provided on this website.

If you are concerned that we may have violated your privacy rights, 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 alterative means or at alternative locations. you may complain to us using the contact information fisted on this website. You also may submit a written complaint to 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.

S2G002, 200 American Dental Association. All Rights Reserved

Reproduction and use of this form by dentists and their staff are permitted. Any other use, duplication or distribution of this form by any other party. requires the prior written approval of the American Dental Association.

This Form is educational only. does not constitute legal advice, and covers only federal, not state, law (August 14, 2002; April 30, 2009).

Authorization for use or disclosure of protected health information

(Required by the Health Insurance Portability and Accountability Act – 45 CFR Parts 160 and 164)

1. I hereby authorize Dr. Jason Keefe and associates to share my dental records with my insurance company(s) for billing purpose and other health care providers if I am referred out for specialty treatment.
a. This information may be used by the person I authorized to receive this information for medical treatment or consultation, billing, or claims payment, or other purposes as I may direct.

2. I authorize disclosure of information regarding my billing, condition, treatment and prognosis to the following individual(s).

3. This authorization shall be in force and effect until revoke permission

a. I understand that I have the right to revoke this authorization, in writing, at anytime. I understand that a revocation is not effective to the extent that any person or entity is already acted in reliance on my authorization of if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

4. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I signed this authorization

5. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.