We want all of our patients to enjoy lasting oral health. We want your family to enjoy long lasting oral health, without finances and insurance coverage being a major concern. Being uninsured is not a problem anymore.
*Membership ends yearly on anniversary of enrollment whether used or not. Fees are subject to change.
By signing this agreement you agree to all the terms and conditions above of the Wellness Plan.
Our office has always been happy to work with patients covered by dental insurance. We think insurance is a great incentive to maintain a vital level of dental health. But it's a rare-very rare-dental plan that covers 100% of our fees.
The fees we charge for dental services are the same for every patient, insured or not. A given insurance policy, however, is based on a fixed fee schedule-"usual & customary"-that may have nothing to do with the real world. Dentistry has changed very quickly, insurance fee schedules have not. After all, insurance companies are profitable businesses, not dental benefactors.
Further, insurance companies reimburse you an amount they figure is commensurate with average quality dentistry in an average office with an average staff, "average" falling somewhere between the best dentistry and the worst dentistry.
Well, we have a better opinion of our services. Our belief is, and always has been, that the style and quality of our dentistry had better be the best.
We're happy to help you with any insurance questions you may have. We'll go over your policy with you, try to maximize your benefits, and request a predetermination of benefits to let you know what your insurer will pay. But please remember your insurer dictates your coverage-we don't. Unless we have a contract with your insurance company (Northeast Delta) we will bill your insurance as a courtesy to you. The patient assumes responsibility for the balance regardless of insurance.
Once an appointment is made, time is reserved exclusively for you, even if you do not come. For this reason you will be financially responsible for that appointment, unless you cancel the appointment more than 24 hours in advance or an emergency prevents you from keeping this time. NOTE: Insurance's do not pay for missed appointments.
Payment is due at the time services are rendered. This includes copayments and deductibles, (balances not paid by the insurance). We accept cash, check, MasterCard, Visa and Discover for your convenience. Any check that is returned from the bank will be charged a $25.00 fee. Balances over 60 days will be charged 1.3% per month, 18% annual finance charge.
If we do not receive or have the following information on your day of service, you will be expected to pay in full. Due to HIPPA laws and time we cannot call insurance companies for this information. Please contact the policy holders HR department for this information.
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 08/16/2022 and will remain in effect until we replace 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 addition- al copies of this Notice, please contact us using the information listed at the end of this Notice.
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:
We may use or disclose your health information to a physician or other healthcare provider pro- viding treatment to you.
We may use and disclose your health information to obtain payment for services we provide to you. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals. evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any pur- pose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.
We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you will opportunity tu ubijelu oli veo u Jouluaurea. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reason- able inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
We will not use your health information for marketing communications without your written authorization.
We may use or disclose your health information when we are required to do so by law.
We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may dis close your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelli- gence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circum- stances.
We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).
You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $0.99 for each page. $25 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)
You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
You have the right to request that we communicate with you about your health infor mation by alternative means or to alternative locations. (You must make your request in writing.) 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.
You have the right to request that we amend your health information. (Your request must be in writing. and it must explain why the information should be amended.) We may deny your request under certain circumstances.
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.
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.
Contact Officer: Evelyn M. Bryan, D.M.D.
Address: 765 S. MAIN ST., STE. 202 MANCHESTER, NH 03102
© 2002 American Dental Association
All Rights Reserved
Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication, or distribution of this form by any other party requires the prior written approval of the Amencan Dental Association.
This form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002)