NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
Shewey Family Dentistry
I understand that under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
Dr. Christian J. Shewey DDS
In our continued commitment to provide the highest quality dental care available to all of our patients and to have those services comfortable and affordable, we are pleased to offer you these options for payment:
Regrettably, as a third party, we cannot assume the responsibility of knowing each and every individual insurance plan and limitations. There are literally hundreds of insurance plans on the market. We cannot afford to assume the financial responsibility this imposes on us and remain in the dental business.
We, therefore, find it necessary to encourage our patients to be familiar with their insurance coverage and limitations on an ongoing basis. DO NOT HESITATE TO CALL YOUR INSURANCE COMPANY. YOU HAVE EVERY RIGHT TO RECEIVE AN ORAL OR WRITTEN REPLY.
I agree that I am fully responsible for the total payment of all procedures performed in this office- this includes any treatment that is not a benefit of any dental insurance that I may have. I understand that my ESTIMATED patient portion is due to be paid in full at the time of treatment. Any outstanding insurance benefits not received by this office within ninety (90) days of the date of service will be my responsibility. Any outstanding balance after ninety (90) days and every month thereafter will accrue a 1% finance charge.
CANCELLATION POLICY: A $50.00 fee will be charged for each appointment hour cancelled or rescheduled without giving 2 business days notice.
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 medication that you may be taking, could have an important interrelationship with the dentistry you will receive.
Thank you for answering the following questions.
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 the dental office of any changes in medical status.