IF YES, PLEASE HAVE ALL INFORMATION READY FOR INTAKE AND BENEFIT ESTIMATE
If you take any medications for any of these conditions, select yes and list the medication(s) and explain.
If you have any allergies or adverse reactions, select yes, and explain.
If you have any current medical treatment or if you have had any of these conditions, select yes and status.
The Endodontic Center of Pleasanton
Lauren T. Phan, DDS APDC
Notice of Privacy Practices
All information the is obtained from you by this office is protected and kept confidential.
Every reasonable measure to prevent unauthorized disclosure of your protected health information is practiced.
Uses and Disclosures
- Your protected health information is accessed and used for healthcare-related purposes only.
- Your protected health information is never sold, rented, transferred, exchanged, and/or use for non-healthcare related purposes including marketing activities without your written authorization.
- Your protected health information is disclosed to third-party entities without your written authorization for the purpose of treatment, to obtain payment for treatment and for healthcare operation.
- Medical Emergencies
- In situations required by law
- Individuals involved in your care
- When required by public agency
- When required by law enforcement agency
- If this practice is sold, your information will become the property of the new owner
For any purpose other than treatment, obtaining payment, healthcare operations, or certain circumstances, we will ask for your written authorization before using or disclosing your protected health information. If you choose to sign an authorization to disclose protected health information, you can revoke that authorization in writing at any time.
We may use your information to contact you. For example, we may send a newsletter or other information. We may also want to call and remind you about your appointments. If you are not home, we may leave this information on your answering machine or with the person who answers the phone.
You have the right to request the following in writing:
- Copy of your health information.*
- An alternate means or location to receive communications regarding your health information.*
- To amend, correct,or delete any recorder health information within our process.*
- To restrict some of the uses and disclosures of your health information.*
- An accounting of certain disclosures of your health information that were made by this office.*
*Condition and limitation may apply: obtain additional information from the front desk.
Changes to this Notice: We reserve the right to change privacy practices and the conditions of this notice at any time and without prior notice. In the event of changes, an update will be posted and a copy will be sent to you.
I, First Name Last Name , do hereby agree to the terms set forth above and any subsequent changes in the office policy.
We strive to provide an affordable option to save your teeth. We realize that every person's financial situation is different.
IF YOU HAVE DENTAL INSURANCE. YOUR PRE-ESTIMATED INSURANCE BENEFIT IS NOT A GUARANTEE OF PAYMENT. IT IS ONLY AN ESTIMATE. THE INSURANCE POLICY IS AN AGREEMENT BETWEEN YOU AND THE INSURANCE COMPANY. YOU ARE DIRECTLY RESPONSIBLE FOR ALL CHARGES.
PRE-ESTIMATED CO-PAYMENTS WITH OR WITHOUT DENTAL INSURANCE ARE DUE BEFORE RENDERING TREATMENT. WE RESERVE THE RIGHT TO SEND YOUR ACCOUNT TO COLLECTIONS IMMEDIATELY IF YOU DO NOT UPHOLD THIS POLICY.
TREATMENT PROCEDURES ARE SUBJECT TO CHANGE DURING THE TIME OF TREATMENT AND WILL BE REFLECTED IN ANY FEE CHANGES.
BENEFITS ARE CALCULATED BASED ON CURRENT AVAILABLE BENEFITS, PATIENT ELIGIBILITY, AND ANY PROFESSIONAL COURTESIES. WE MAKE EVERY ATTEMPT TO HELP YOU RECEIVE THE MAXIMUM REIMBURSEMENT TO WHICH YOU ARE ENTITLED.
ESTIMATES ARE SUBJECT TO MODIFICATION BASED ON ELIGIBILITY, COORDINATION OF BENEFITS, THE BENEFIT PLAN IN EFFECT AT THE TIME SERVICES ARE COMPLETED, AND ANY PROFESSIONAL COURTESIES.
AS A COURTESY, WE WILL SUBMIT THE CLAIM TO YOUR INSURANCE CARRIER FOR THE RENDERED PROCEDURES. IF THERE IS ANY REMAINING BALANCE AFTER YOUR INSURANCE PAYS, WE WILL SEND YOU A STATEMENT VIA POSTAL MAIL, WHICH IS DUE UPON RECEIPT.
IF YOU DO NOT AGREE WITH OUR PRE-DETERMINED ESTIMATE, YOU HAVE THE RIGHT TO FILE THE CLAIM TO YOUR INSURANCE CARRIER AND RECEIVE DIRECT PAYMENT FROM THEM. YOU WILL BE REQUIRED TO PAY THE FULL FEE AT OUR OFFICE PRIOR TO TREATMENT.
IT IS YOUR RESPONSIBILITY TO PROVIDE US WITH ACCURATE INFORMATION FOR YOUR DENTAL INSURANCE CARRIER(S). INCORRECT INFORMATION WILL DELAY INSURANCE CLAIMS AND PAYMENTS. WE SUBMIT TO YOUR CARRIER AS A COURTESY. IF INCORRECT, PAYMENT IN FULL OR RENDERED PROCEDURES WILL BE BILLED TO YOUR ACCOUNT AND DUE UPON RECEIPT. YOU WILL RECEIVE A BILL VIA POSTAL MAIL. YOU MAY THE RESUBMIT THE CLAIM YOURSELF FOR REIMBURSEMENT FROM YOUR DENTAL INSURANCE CARRIER.
UNPAID BALANCES AFTER 30 DAYS ARE SUBJECTED TO LATE FEES AND CHARGED INTEREST. UNPAID BALANCES WILL BE SENT TO COLLECTIONS AFTER 90 DAYS.
RETURNED CHECKS (INADEQUATE FUNDS) ARE SUBJECT TO A $50.00 CHARGE.