At Meadowmont Dentistry, we promise to listen carefully to your concerns and provide you with the highest quality, personalized dental care possible!  Our goal is to exceed your expectations and your comfort is our top priority.  You deserve it!

Please take a moment to complete the following questions to help us serve you best.

SMILE ASSESSMENT. Everyone deserves an attractive and confident smile!

*Would you like to see just how amazing your smile could be? Ask a Team member how to receive a complimentary Smile Simulation (before and after). Let us show you your dream smile!

Finally - We want your experience with us to be truly 5-star. We want to exceed your expectations!

*By signing below, I authorize my insurance company to pay Meadowmont Dentistry all insurance benefits rendered. I authorize the use of this electronic signature on all insurance submissions. I authorize Meadowmont Dentistry to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges, whether or not paid by insurance. *

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medications that you may be taking, could have an important interrelationship with the care you will receive. Thank you for answering the following questions.

*NOTE: Antibiotics may alter the effectiveness of birth control pills. Consult your physician for assistance regarding additional methods of birth control

*To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform Meadowmont Dentistry of any changes in my medical history or medications*

Meadowmont Dentistry is authorized to release protected health information about the above-named patient in the following manner and to identified persons.

Our mission is to treat each patient as we would like to be treated: with kindness, understanding and skill. Our staff is dedicated to providing the highest quality care at a fee that is reasonable and fair. We appreciate you choosing Meadowmont Dentistry for your dental care and express this appreciation by giving back to our community and profession.

Dental Insurance:

• As a courtesy, we will complete and submit dental insurance claims in an effort to obtain maximum reimbursement to which you are entitled. Based on the information available to us, we will estimate your deductible and the portion not covered by your insurance. This amount will be due at the time of treatment
• We are an “in-network” provider for only a few insurance companies. Your ESTIMATED out of pocket expense is dictated by your insurance coverage.  Every insurance company has its own “usual and customary” fees and there may be multiple insurance policies offered by the same insurance company.
• Any claims denied or remaining unpaid balances, after 90 days, will automatically become your responsibility.
• You are ultimately responsible for payment of your account, regardless of insurance.
• All past balances exceeding 90 days, without previously agreed-upon financial arrangements, will be referred to a collection agency or small claims court.
• You agree to reimburse Meadowmont Dentistry the fees of any collection agency, which will be added to the account at the time it is placed with the collection agency and you will be charged a one-time fee of 24% of the debt, along with all costs and expenses, including reasonable attorneys' fees, we incur in such collection efforts.

Payment Policy:

• Payment is expected and appreciated at the time the services are rendered. We gladly accept cash, check, Master Card, VISA, American Express, Discover, or a payment plan through a third-party financing company such as Care Credit.
• A $25 service charge will be assessed for all checks returned due to insufficient funds.
• In the event that you suspend or terminate care, any fees for services rendered will be due immediately.
• If you would like your dental records sent to another office, a copying fee may be applied. 

Missed Appointments/Late Cancellations:

• We reserve the right to charge a $75 fee for missed appointments or cancellations, with less than 48 business hours notice.
• If you have a history of three or more broken appointments or have cancelled your appointment three or more times, without at least 48 business hours notice, you may be discharged from the practice.

Deposit for Scheduled Appointments:

• For all appointments requiring 90 minutes or more, a $200 deposit will be due at the time of scheduling.  This deposit will be applied to your procedure fee.  The deposit will be forfeited if the appointment is cancelled with less than 48 business hours notice or if you do not show for your appointment.

Consent for Treatment

• I hereby authorize Meadowmont Dentistry and/or staff to take x-rays, models, photographs, or other diagnostic aids deemed appropriate to make a thorough diagnosis of my dental needs. Upon such a diagnosis, I authorize Meadowmont Dentistry to perform all recommended treatment mutually agreed upon, and to employ such assistance as required to provide proper care. I agree to the use of anesthetics, sedatives, and other medications as necessary, and I fully understand that use of these agents carries certain risks. I understand that I can ask for an explanation of possible complications at any time.

*I certify that I have read, understand, and agree to the “Office Financial Policies” and the “Consent for Treatment Policy” listed above and have had all questions answered to my satisfaction.

By signing below, I acknowledge that I received the Financial Policies form and agree to abide by such policies.

THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED BY MEADOWMONT DENTISTRY AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

YOUR RIGHTS: When it comes to your health information you have certain rights. This section explains your rights.

Upon written request:

• Ask to see or get an electronic or a paper copy of your health record or other information we have about you. We will also provide a summary of your health information if requested. We will charge a reasonable, cost-based fee. We will provide this information as soon as possible but no later than 30 working days of the request.
• Ask us to correct your health information you think is incorrect or incomplete. We may say “no” but we’ll tell you why in writing within 60 days.
• You can ask us to communicate with you in a certain way (for example, home or office phone) or to send mail to a different address. We will accommodate all reasonable requests.
• Ask us not to use or share certain health information for treatment, payment or our operations. We are not required to agree with your request and may say “no” if it would affect your care.
• If you pay for a service or health care item out of pocket in full and you ask us not to share that information for payment or our operations with your health insurer we will agree unless we are required by law to share that information.
• Ask us for a list or an accounting of the times we have shared your health information for reasons other than treatment, payment, healthcare operations, and when you have asked us to share information. We will provide a list for the past six years for the request. One request per year will be provided free of charge. For additional requests, we will charge a reasonable, cost-based fee.
• Revoke an authorization to use or disclose PHI at any time except where action has already been taken.

You may also:

• Choose someone to act on your behalf. If you have given someone medical power of attorney or they are your legal guardian, that person can exercise your rights and make choices about your health information. We will ask for proof of this relationship before we take any action.
• Ask for a paper copy of this document even if you have agreed to receive the notice electronically. We will provide that copy promptly.
• File a complaint. If you feel your rights have been violated you may contact the designated Privacy Officer, [Ashley Thomas, 400 Meadowmont Village Circle Suite 427 Chapel Hill, NC 27517, 919-969-9330 (Phone) and admin@meadowmontdentistry.com ]
• File a complaint with the US Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Ave, S.W., Washington, D.C. 20201, calling 1.877.696.6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints .
• We will not retaliate for filing a complaint.

OUR RESPONSIBILITIES: The law requires us to:

• Maintain the privacy and security of your protected health information.
• Notify you promptly if a breach occurs that may compromise the privacy or security of your information.
• Follow the duties and privacy practices described in this notice and give you a copy of it.
• Not to use or share your information other than what is described in this notice unless you tell us we can in writing. If you tell us we can and then change your mind, just let us know in writing you have changed your mind.

YOUR CHOICES - For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in situations described below, talk to us.

• In these cases, you have both the right and the choice to tell us to: share information with your family, close friends, or others involved in your care and share information in a disaster relief situation. 

If you are not able to tell us your preference, for example, if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.  

In these cases we never share your information unless you give us written permission:

• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes
• In the case of fundraising, we may contact you for fundraising efforts, but you can tell us not to contact you again.

OUR USES AND DISCLOSURE – We typically use or share your health information in the following ways:

Treatment: We can use your health information and share it with other professionals who are treating you. Example: We may share your health information to an outside doctor for referral. We will also provide your health care providers with copies of various reports to assist them in your treatment.

Payment: We can use or share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your healthcare.

Health Care Operations: We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services.

Other ways we can use or share your health information – We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.

• Help with public health and safety issues: We can share health information about you for certain situations such as: preventing disease, helping with product recalls, reporting adverse reactions to medication, reporting suspected abuse, neglect, or domestic violence, and preventing or reducing a serious threat to anyone’s health and safety.
• Comply with the law: We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see if we are complying with federal privacy law.
• Respond to organ and tissue donation requests: We will share health information about you with organ procurement organizations.
• Work with a medical examiner or funeral director: We can share health information with a coroner, medical examiner, or funeral director when you die.
• Address workers’ compensation, law enforcement, and other government requests:
  • For workers’ compensation claims
  • For law enforcement purposes or with a law enforcement official
  • With health oversight agencies for activities authorized by law
  • For special government functions such as military, national security, and presidential protective services
• Respond to lawsuits and legal actions: We can share your health information to respond to a court or administrative order, or in response to a subpoena.
• Research: We can use or share your information for health research.

CHANGES TO THIS NOTICE - We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.

Ashley Thomas

admin@meadowmontdentistry.com

919-969-9330

Effective date: August 2017 Revision Date: May 2019

Notice of Privacy Practices

By signing below, I acknowledge that I have read the Notice of Privacy Practices, as mandated by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”)