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It is customary to pay for services at the time they are rendered unless prior arrangements have been made. We will accept cash, personal checks, Visa or MasterCard. Dental Fee Plan and CareCredit are available for those who desire a payment plan. Balances of $300 or more can be transferred to one of our financing companies at any time. Applications for both are available at the front desk. Credit approval can usually be obtained over the phone or on-line in as little as 10 minutes. Any payment plan must be in writing before your appointment.

To keep the cost of dentistry as low as possible, appointments are scheduled to best fit the patient’s and the doctor’s time. 48-hour notice is required to contact patients on the waiting list. There may be a charge for any missed or rescheduled appointments with less than 48 hours notice at the rate of $25.00 per half hour scheduled. We also reserve the right to dismiss you as a patient of record if more than 2 appointments are missed.

All insurance co-pays and deductibles are due at the time of treatment. As a courtesy to our patients we submit billing to most insurance companies. However, we can make no guarantee of coverage; and fees are patient responsibility regardless of insurance coverage. Our office will do everything possible to see that you receive the full benefits of your policy. If insurance has not paid within 60 days of services rendered, the balance will be automatically due and payable. We strive to give accurate information regarding insurance benefits. However, it is the responsibility of patients to know their own benefits and keep track of the yearly amount used. This office is not responsible for “over maximum” or non-paid deductibles or for any other reason the insurance company does not pay a benefit. You are responsible to keep track of your waiting periods for major and implant services. Check with your insurance company for complete details. All insurance benefits are an estimate only. Please be sure to give accurate insurance information to our front office. Incorrect billing could incur a $10.00 billing charge.

Our practice is committed to providing the best treatment for our patients. Please be aware that some of the services provided may be non-covered services and not considered reasonable and necessary under individual insurance policies.

We charge what is usual and customary for our area for the level of quality we provide. You are responsible regardless of any insurance company’s arbitrary determination of usually and customary rates. A finance charge of 18% per annum will be charged on all balances over 60 days.

Because it is not possible, in some cases, to verify benefits at the time of the emergency appointment, you will be expected to pay in full, at the time services are rendered, regardless if you have insurance coverage. We will be happy to fill out and submit any necessary insurance paperwork and will reimburse you when the insurance has paid.

There is a $25.00 fee for returned checks.

I have received a copy of the Dental Board of California Fact Sheet on Dental materials and HIPPA Agreement as mandated by California State and Federal Law.

I have read a copy of the HIPAA information and have received a copy if I requested one.

Release of Information/Financial Responsibility/Assignment of Benefit: I hereby authorize the office of Steven R. Walls, DMD to affix my name to any and all claims or documents as related to any and all health benefits due me and my dependents through my employment. I hereby authorize payment of dental benefits otherwise payable to me, directly to the office listed above. I have read, understand and agree to the terms and conditions of this document. To the extent permitted under applicable law, I authorize release of any information relating to insurance claims.

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment, employee review, training of medical students, licensing, fundraising, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment, and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by law, public health issues as required by law, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity and national security, workers’ compensation, inmates, and other required uses and disclosures. Under the law, we must make disclosures to you upon your request. Under the law, we must also disclose your protected health information when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements under Section 164.500.

Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object unless required by law. You may revoke the authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

The following are statements of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information (fees may apply) – Under federal law, however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of, or used in, a civil, criminal, or administrative action or proceeding, protected health information restricted by law, information that is related to medical research in which you have agreed to participate, information whose disclosure may result in harm or injury to you or to another person, or information that was obtained under a promise of confidentiality.
You have the right to request a restriction of your protected health information – This means you may ask us not to use or disclose any part of your protected health information and by law we must comply when the protected health information pertains solely to a health care item or service for which the health care provider involved has been paid out of pocket in full. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. By law, you may not request that we restrict the disclosure of your PHI for treatment purposes.

You have the right to request to receive confidential communications – You have the right to request confidential communication from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

You have the right to request an amendment to your protected health information – If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures – You have the right to receive an accounting of all disclosures except for disclosures: pursuant to an authorization, for purposes of treatment, payment, healthcare operations; required by law, that occurred prior to April 14, 2003, or six years prior to the date of this request.

You have the right to obtain a paper copy of this notice may from us even if you have agreed to receive the notice electronically. We reserve the right to change the terms of this notice and we will notify you of such changes on the following appointment. We will also make available copies of our new notice if you wish to obtain one.

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Compliance Officer of your complaint. We will not retaliate against you for filing a complaint.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. We are also required to abide by the terms of the notice currently in effect. If you have any questions in reference to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number.

Please note that by signing this Acknowledgment form you are only acknowledging that you have received or been given the opportunity to receive a copy of our Notice of Privacy Practices.

Dr. Steven R. Walls, DMD

Golden Hills Family Dental

3941 Park Drive, Suite 50

El Dorado Hills, CA 95762

NOTE: This authorization is intended to comply with applicable state laws. It is not intended as a “Consent” or “Authorization” for the use and disclosure of Protected Health Information (PHI) under the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) or its implementing regulations. The medical provider to whom this authorization is directed should ensure that he or she is in compliance with applicable HIPPA requirements before releasing information.

CAUTION: If you intend to use the requested information for any purpose other than providing medical treatment, 45 CFR Section 164.502 requires that you make reasonable efforts to limit your request for PHI information to the minimum necessary to accomplish the intended purpose of the request.

To be valid, an authorization must clearly separate from other language on a page and executed by a signature which serves no other purpose other than to execute this authorization. It can either be handwritten by the person who signs is or in typeface no smaller than 8 points.