Ai-Lien Sperry, D.M.D., P.S. | Sperry Dentistry | 4820 NE 4TH ST. Suite #A-108 | Renton, WA 98509 | 425.687.2876
OUR OFFICE POLICY
Our office is committed to providing you with the best quality of dental care. In order to achieve this goal, we need your cooperation as well as your understanding of this payment policy. Payment for services is due at the time the care is provided, unless other arrangements are made with our Business Manager. For your convenience we offer the following methods of payments: Cash, Checks, Visa, MasterCard, Discover, and AMEX. A fee of $35.00 will be assessed on any returned check. A charge of $75.00/hr is made for broken or cancelled appointments without 48 hours notice (excluding weekends and holidays).
PATIENT RESPONSIBILITIES REGARDING DENTAL INSURANCE
If you have dental insurance, we will gladly submit claims for you; provided we are given complete and accurate insurance information, as well as a release of benefits and information to your insurance company. We can estimate your insurance benefits for you; however we cannot guarantee payments. These estimates are based on your exams & x-rays. Changes in proposed treatment may need to be made due to clinical considerations. Your dental insurance is a contract between you and your insurance company; it is your responsibility to be aware of annual maximums and contract limitations. You are responsible for payment for services received from Dr. Sperry in accordance with the office regular fees and terms. Your responsibility is not modified by whether any third party (insurance) pays for all, part, or none of the charges.
AUTHORIZATION AND RELEASE
Permit for treatment and/or surgical care: I hereby grant permission to Dr. Sperry, or her assignee, to employ such established treatments and therapy as may be deemed professionally necessary and advisable.
Financial agreement: All charges for services and treatment will be paid upon completion of appointment. I understand that this account becomes delinquent if not paid within 60 days after billing and that at this time a Finance Charge of 1.5% (18% per annum) per month will be applied on the unpaid balance. In the event of default, I agree to pay all legal indebtedness together with such collection costs if suit be instituted hereunder. I authorize all credit inquiries deemed necessary in connection with my account.
Insurance: I hereby authorize payment directly to Dr. Sperry, the dentist, otherwise payable to me.
November 16, 2019
HIPAA NOTICE OF PRIVACY PRACTICES
OUR LEGAL DUTY
Federal and state law requires us to maintain the privacy of your health information. That law also states we must provide you with this notice regarding our privacy practices, our legal obligations and your rights concerning your personal health information (PHI). We will follow these practices described in this notice until such time it is amended. This notice will take effect on April 14, 2003 and will remain so until we amend 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.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
Our office may use and disclose your personal health information for treatment, payment and other healthcare operations in the following manner:
Treatment Information: Our office may use and disclose your health and insurance information to a referring Dentist, to your Physician and/or any other healthcare provider who is involved in your treatment past, present and future.
Payment of Services Rendered: Our office may use and disclose your information as you reported on our registration form to obtain payment for services rendered. This may be disclosed to an insurance company, any healthcare provider or entity involved in your treatment and any other agency for the use of collection purposes. These entities will be subject to the Federal Privacy Rules and Regulations.
Healthcare Operations: Our office may use and disclose your health information for our healthcare operations. We may disclose your health Information to another healthcare provider or organization which you are affiliated with to support their healthcare operations. These entities will be subject to Federal Privacy Rules and Regulations. We may disclose your information to them for their own internal purposes and to detect or prevent healthcare fraud.
Your Authorization: You may give us written authorization to disclose your information to anyone for any purpose. You may revoke this privilege at anytime in writing. Revocation of your information does not affect information while permission was granted. Unless we have written authorization from you we cannot release information to anyone for any reason unless described in this notice.
Your Family and Associates: We may disclose your information to family members and associates for the purpose of aiding in your healthcare or payment for services rendered. Before any personal health information is disclosed we will give you an opportunity to decline the use or disclosure of your information. If you are unable to give consent due to absence or emergency, we will use our professional judgment to disclose in your best interest, to include: drug prescriptions, supplies, x-rays and health forms. We may disclose your health information to notify or assist another in your care, location and general condition.
Appointment and Pre-Medication Information: We may use or disclose information about you for the purpose of reminders for appointments in the form of phone calls at home or work to include voicemail messages, in the form of e-mail or text, in the form of postcards and or letters. We may also use mail and telephone for financial disclosure.
Disaster Policy: We may use or disclose your health information to any entity, public or private authorized by law in the event of a disaster to assist in relief efforts.
Public Benefit: We may use or disclose your health information as authorized or required by law if merited to be in the best interest of the public in the following ways:
- As required by law or Department of Health and Human Services
- For public health reporting including disease and vital statistics, reporting of child abuse, FDA oversight and to employers in regards to work related illness or injury
- In the reporting of domestic violence, adult abuse and neglect
- In response to a court order or other lawful purpose as required
- To law enforcement officials or other lawful agencies for information pertaining to crimes being investigated, crimes on our premises and for location or identifying a possible suspect in a crime
- To coroners, funeral directors or medical examiners
- To avoid serious threat to health or safety
- If requested for research activities
- To the military and federal officials for national security
- To corrections officials regarding inmates
- And as authorization by Washington Labor and Industries laws
Accessing Your Records: You have the right to ask to see your records with limited exceptions. The health records we create and store are the property of the practice. The protected health information, however, generally belongs to you. You must make your request in writing. We will have a form available for your use, if you are not to use our form you may mail in your written request as directed at the end of this notice. We will comply or reply within the state and general guidelines. You will be charged a fair and reasonable fee as set forth by state and federal regulations to include copy charges, labor and postage. You may obtain more information on contacting us at the end of this notice.
Disclosure of Information: You have the right to request a list of instances when our business associates or our office may have used or disclosed your health information. You may request information for 6 years back but not prior to April 14, 2003. If you request information more than 1 time in a 12 month period, a charge as stated will be assessed, not to exceed guidelines set forth by state and federal laws. Treatment, payment, healthcare operations and certain other charted information will be excluded. Please contact us as described below for any questions or requests.
Restrictions of Disclosure: You have the right to restrict the use or disclosure of your health information in writing. We are not required to accept a request; however, if we do we must follow through with your request, except in emergency. Your request is not binding unless it is in writing.
Alternative Communication: You have the right to request we contact you in an alternate means or location about your health information. You must make this request in writing and it must not circumvent the way you will pay for your services rendered. Your request must be reasonable and effective in contacting you. 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 ask us to amend your health information. Your request must be in writing along with an explanation as to why we should amend your information. There are certain circumstances in which we may deny your request.
Electronic Notice: If you receive this Notice on our Web site 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.
If you are concerned that we may have violated your privacy rights, or 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 alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. 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.
ACKNOWLEGEMENT OF PRIVACY PRACTICES
My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to:
- Provide and coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly
- Obtain payment from third-party payers for my health care services
- Conduct normal health care operations such as quality assessment and improvement activities
I have been informed of my dental provider’s Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices.
I am legally authorized to sign on my behalf or on the behalf of the patient as a guardian Relationship to the patient
November 16, 2019