• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.
• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.
• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make).
• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.
• You can complain if you feel we have violated your rights by contacting us using the information on page 1.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes
How do we typically use or share your health information?
We typically use or share your health information in the following ways:
We can use your health information and share it with other professionals who are treating you
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
We can use and share your health information to bill and get payment from health plans or other entities.
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. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html
• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html
Changes to the Terms of 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 web site.
Patients are expected to pay Heartland OMS LLC for services at the time they are rendered unless prior arrangements have been made. There is a fee for consultations, x-rays, and surgical services provided. There may be times where a deposit is required prior to the day of the surgical procedure. This amount will be determined prior to an appointment being made.
Heartland OMS LLC is not a contracted provider with Medicaid or Medicare. Services may be provided to patients with the understanding that Medicaid or Medicare will not be billed for services rendered.
Payments may be made using cash, check, Visa, MasterCard, American Express, Discover, Care Credit and HSA/FSA accounts. All returned checks will be subject to a $25 fee. There will be a monthly statement sent to all patients with an outstanding balance. After an attempt for collection is made, and a grace period of 90 days from the day of service, the patient, the parent, or other legal guardian for the account may be sent directly to the credit bureau to settle the financial obligation.
Heartland OMS LLC will submit claims to the patient’s insurance company. To maximize insurance benefits, the most recent insurance card and/or insurance policy must be provided. Any deductibles and/or estimated copayments must be paid as services are rendered. Although dental insurance claims are submitted as a courtesy to patients, all account balances are ultimately the responsibility of the patient, the parent, or other legal guardian.
If the insurance denies the claim, the patient, the parent, or other legal guardian will become fully responsible for services rendered.
Heartland OMS LCC understands that emergencies happen, and patients are not always able to keep the originally scheduled appointment. To be respectful of other patient’s needs, contact must be made promptly with the office if an appointment needs to be cancelled or rescheduled. This allows an offer of the reserved appointment time to a patient in urgent need of treatment.
The initial visit may require radiographs to complete the examination, diagnosis, and treatment plan. There are some cases where a dental insurance plan may not cover the fee for the x-ray(s). If this is the case, the patient, the parent, or other legal guardian will be financially responsible for the x-ray fee.
If dental x-rays were taken at another office, Heartland OMS LLC will attempt to obtain these. If the attempt is unsuccessful to retrieve the x-rays needed to diagnose and treat the patient, or if the x-rays are outdated, a new x-ray may need to be taken, possibly resulting in an additional fee.
Heartland OMS LLC has the right to refuse treatment to any person for any reason that is non-discriminatory. If treatment is refused, the patient has the right to question the reason. When a patient is dismissed from the practice, a written notice will be sent. At that time, the patient can be seen on an emergency only basis for 30 days to allow time to find another provider.
Patients also have the right to refuse accepting treatment. In this case there will be a discussion about the possible risks and complications due to refusing the recommended treatment.
There are many reasons Heartland OMS LLC may need to contact patients and most of the communication will happen in person and over the phone. However, there may be use of a HIPAA compliant communication software that allows secure electronic communication between patients and staff. Private health information may be sent, such as appointment confirmations, procedure instructions and test results to a patient’s email, and/or cell phone. Patients are able opt out of electronic communications by marking this on the new patient paperwork, or by letting administrative staff know.
I understand the information disclosed in this form may be subject to re-disclosure and may no longer be protected by HIPAA privacy regulations and the HITECH Act.
