We are committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information we collect, use, and disclose. In addition to the circumstances described in this form, we also collect, use, and disclose personal information when permitted or required by law.
We collect information from our patients such as names, addresses, telephone numbers, and email addresses (collectively referred to as “Contact Information”). Contact information is collected and used for the following purposes:
- To open & update patient files
- To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts
- To process claims for payment or reimbursement from third-party health benefit providers and insurance companies
- To send reminders to patients concerning the need for further dental examination or treatment via email and text
- To send patients informational material about our dental practice
Contact Information is disclosed to third-party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf.
“Financial Information” may be collected in order to make arrangements for the payment of dental services.
We collect information from our patients about their health history, physical condition, and dental treatments (collectively referred to as “Medical Information”). Patient’s Medical Information is collected and used for the purpose of diagnosing dental conditions and providing safe dental treatment.
Patient’s Medical Information is disclosed:
- To third-party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment on all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf
- To other dentist’s and dental specialists, where we are seeking a second opinion and the patient has consented to us obtaining the second opinion
- To other dentist’s and dental specialists if the patient, with their consent, has been referred to us by the other dentist or dental specialist for treatment
- To other dentists and dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion
- To other health care professionals such as physicians if the patient, with their consent, has been referred to us by the other health care professional for either a second opinion or treatment
On our patient’s behalf, our dental office will submit the primary and secondary insurance claims and request that your benefit company pays our office directly for your services. Our patients are required to pay any remaining balance at the time of the appointment, if the benefit company does not pay in full. In the event that your benefits do not tell us what they will be paying, we do require a credit card be left on file so that we can apply the difference once payment is received.
If your policy does not allow for payment directly to our office, the patient is responsible for payment in the full amount at the time of the appointment. We will submit dental claim forms on your behalf and have the insurance company reimburse you directly. If you do not have any dental benefits, we do require payment in full at the time of your appointment.