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Blatchley Family Dentistry

426 E. Barcellus Ave #105,
Santa Maria, CA 93454
(805) 347-4785

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
Responsible Party's Information( * mandatory to fill )
Emergency Contact Information( * mandatory to fill )
Primary Insurance Details( * mandatory to fill )
Financial Policy( * mandatory to fill )

Blatchley Family Dentistry (BFD) is committed to providing exceptional service and treatment that addresses both your short and long-term oral health needs. Towards these goals, we would like to explain YOUR financial and scheduling responsibilities with our practice.

1. Clear, written estimate of your treatment cost

BFD will provide you with a comprehensive treatment plan based on your overall health. You will also receive a clear, detailed estimate of the cost of your plan, including your estimate insurance benefits. If you have questions regarding your insurance coverage, please contact your employer and/or insurance company.

2. Payment policy

Patient responsibility is due when services are rendered. We accept cash, personal checks, all major credit cards, most dental insurance plans and third party financing thorough Care Credit and Wells Fargo. Financial arrangements are discussed during the initial visit and a financial agreement is completed in advance of performing any treatment with our practice. There will be a$25 fee added to your account for returned checks. There is a $20 fee for copies or transfer of dental records.

3. Refund policy

You may cancel your treatment and request a refund of the treatment which was already paid for but not completed, after consultation with doctor. Note: Crown and bridge patients are responsible for the full cost of their treatment plan once preparation of your teeth has begun. Invisalign patients are responsible for the full cost of all laboratory costs and scan fees once fabrication of your aligns has begun. Refund request must be submitted in writing. Request can be dropped off at the office or submitted via e-mail to info@blatchleyfamilydentsitry.com

If approved, the refund will be in the form of check within 10 days from refund request. You will receive a letter indicating the refund amount. If you disagree with the amount refunded you have the right to submit an appeal in writing. Appeals will be responded to within 30 days.

4. Dental insurance

Your dental benefit is a contract between you and your employer and the dental benefit plan. Benefits and payments received are based on the terms of your contract negotiated between you or your employer and the plan. We are happy to process your insurance claims and help review dental benefit plans to understand and maximize your coverage.

In Network: If your dentist is a participating provider in your insurance network, you are responsible only for your portion of the approved fee as determined by your plan. We are required to collect the patients portion (deductible, co-insurance, co-pay or any amount not covered by the dental benefit plan) in full at time of service. If our estimate of your portion is less than the amount determined by your plan, the amount billed to you will be adjusted to reflect this.

Out of Network: If your dentist is not participating or in-network provider with your insurance plan, we will honor your carriers in network fee structure. If your insurance carrier will not accept your assignment of benefits to your dentist, you are responsible for the estimated insurance benefit.

 

Insurance discounts: Insurance companies often negotiate discounts for services provide to their plan members. If you exceeded your annual benefit limit the insurers discounted rate may apply to additional services as a benefit to you.

5. Third party financing

BFD accepts payment from Care Credit and Wells Fargo, non-affiliated third party finance companies. Credit decision are the responsibility of these third-party finance companies. You may choose to pay all or a portion of your treatment using approved third-party financing products. *Please note: If you elect to apply for third-party financing, administered through our practice, we are required by law to provide you with a Credit for Dental Services Notice.

6. Patient communication

We would like to keep in touch regarding your upcoming appointments, treatment plan and treatment status. By providing your email address, phone number, and mailing address you are giving BFD permission to contact you through one or all of these communication methods. Note that email and text messaging is not secure and there is a risk that they could be read by a third party. By sharing your email and/or mobile number with us you are acknowledging that you are aware of this risk and agree to receive this type of communication. BDF will limit the type of information in the messages. You can withdraw your consent at any time by unsubscribing to e-mail and/or text messages.

7. Scheduling of appointments
We reserve the doctor and hygienists time on the schedule for each patient procedure and are diligent about being on time. Because of this courtesy, when you cancel an appointment, it affects the overall quality of services we are able to provide. To maintain the utmost service and care, we do require 48-hour notice to reschedule appointment. For notice less than 24-hours, on confirmed appointments, a cancellation fee of $75 will be charged to your account. To serve all of our patients in a timely manner, we may need to reschedule your appointment if you are 15 minutes late or more arriving to your appointment. To reschedule an appointment due to late arrival, a fee of $75 or deposit to reserve the appointment time again, may be required if this happens more than 3 times.

Patient Authorizations

I understand that the information I have given today is correct to the best of my knowledge. I authorize this dental team to perform any necessary dental services that I may need and have consented to during diagnosis and treatment. I have read the above and agree to the financial and scheduling terms. I authorize the release of information necessary to process my dental benefit claims. I hereby authorize payment directly to this doctor otherwise payable to me.

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Notice of Privacy Practices( * mandatory to fill )

This notice describes how your health information may be used and disclosed and how you can get access to this information. Please review it carefully. The privacy of your health information is important to us.

Our Legal Duty

Federal and state laws require us to maintain the privacy of your health information. We are also required to provide this notice about our offices privacy practices, our legal duties and your rights regarding your health information. We are required to follow the practices that are outlined in this notice while it is in effect. This notice takes effect July 13, 2018 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 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. For more information about our privacy practices or additional copies of this notice, please contact us (contact information below).

Uses and Disclosures of Health Information

We use and disclose health information about you for treatment, payment and health care operations.

For example:

Treatment

We disclose medical information to our employees and others who are involved in providing the care you need. We may use or disclose your health information to another dentist or other health care providers providing treatment that we do not provide. We may also share your health information with a pharmacist in order to provide you with a prescription or with a laboratory that performs tests or fabricates dental prostheses or orthodontic appliances.

Payment

We may use and disclose your health information to obtain payment for services we provide to you, unless you request that we restrict such disclosure to your health plan when you have paid out-of-pocket and in full for services rendered.

Health Care Operations

We may use and disclose your health information in connection with our health care operations. Health care operations include, but are not limited to, quality assessment and improvement activities, reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization

In addition to our use of your health information for treatment, payment or health care operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. 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 is 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.

To Your Family and Friends

We must disclose your health information to you, as described in the Patient Rights section of this notice. You have the right to request restrictions on disclosure to family members, other relatives, close personal friends or any other person identified by you.

Unsecured Emails

We will not send you unsecured emails pertaining to your health information without your prior authorization. If you do authorize communications via unsecured email, you have the right to revoke the authorization at any
time.

Persons Involved in Care

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 your death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. 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 persons involvement in your health care. We will also use our professional judgment and our experience with common practice to make reasonable 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.

Marketing Health-Related Services

We may contact you about products or services related to your treatment, case management or care coordination or to propose other treatments or health-related benefits and services in which you may be interested. We may also encourage you to purchase a product or service when you visit our office. If you are currently an enrollee of a dental plan, we may receive payment for communications to you in relation to our provision, coordination or management of your dental care, including our coordination or management of your health care with a third party, our consultation with other health care providers relating to your care or if we refer you for health care. We will not otherwise use or disclose your health information for marketing purposes without your written authorization. We will disclose whether we receive payments for marketing activity you have authorized.

Change of Ownership

If this dental practice is sold or merged with another practice or organization, your health records will become . the property of the new owner. However, you may request that copies of your health information be transferred to another dental practice.

Required by Law

We may use or disclose your health information when we are required to do so by law.

Public Health

We may, and are sometimes legally obligated to, disclose your health information to public health agencies for purposes related to preventing or controlling disease, injury or disability; reporting abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure. Upon reporting suspected elder or dependent adult abuse or domestic violence, we will promptly inform you or your personal representative unless we believe the notification would place you at risk of harm or would require informing a personal representative we believe is responsible for the abuse or harm.

Abuse or Neglect

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 disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security

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 intelligence, counterintelligence and other national security activities. We may disclose to correctional institutions or law enforcement officials having lawful custody of protected health information of inmates or patients under certain circumstances.

Appointment Reminders

We may contact you to provide you with appointment reminders via text message, voicemail, postcards or letters. We may also leave a message with the person answering the phone if you are not available.

Sign-In Sheet and Announcement

 Upon arriving at our office, we may use and disclose medical information about you by asking that you sign an intake sheet at our front desk. We may also announce your name when we are ready

PATIENT RIGHTS

Access

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 can not 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 contacting our office. 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. If you request copies, there may be a charge for time spent. If you request an alternate 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 for a full explanation of our fee structure.

Disclosure Accounting

You have a right to receive a list of instances in which we disclosed your health information for purposes other than treatment, payment, health care operations and certain other activities for the last six years. 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.

Restriction

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 emergency). In the event you pay out-of-pocket and in full for services rendered, you may request that we not share your health information with your health plan. We must agree to this request.

Alternative Communication

You have the right to request that we communicate with you about your health information 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 of how payments will be handled under the alternative means or location you request.

Breach Notification

In the event your unsecured protected health information is breached, we will notify you as required by law. In some situations, you may be notified by our business associates.

Amendment

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.

Research

Your health information may be disclosed to researchers for research purposes. In this situation, written authorization is not required as approved by an Institutional Review Board or privacy board.

Fundraising

We may use or disclose demographic information and dates of treatment in order to contact you for fundraising activities. If you no longer wish to receive these communications, notify us at the contact information provided below and we will stop sending further fundraising information.

Questions and Complaints

If you want more information about our privacy practices or have questions or concerns, please contact us at:

Contact: Maria Blatchley or Erin Matheson

Telephone: (805) 347-4785 Fax: (805) 347-7487

Email: info@blatchleyfamilydentistry.com

Address: 426 E Barcellus Ave. Suite 105 Santa Maria, CA 93454

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 send a written complaint to our office or to the U.S. Department of Health and Human Services, Office of Civil Rights. We will not retaliate against you for filing a complaint.

Acknowledgment of Receipt of Notice of Privacy Practices

I, have received a copy of the Blatchley Family Dentistry Notice of Privacy Practices.

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If this acknowledgment is signed by a personal representative on behalf of the patient, complete the following

For Program Use Only

We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

  •  Individual refused to sign
  •  Communications barriers prohibited obtaining the acknowledgement
  •  An emergency situation prevented us from obtaining acknowledgement
  •  Other (Please Specify)
BFD Acknowledgements( * mandatory to fill )

Patient Acknowledgements

  •  Federal protection for the privacy of health and personal information is in effect. The HIPAA Notice of Privacy Practices for BFD is available at the front desk when requested or online at our website www.blatcheyfamilydentistry.com. I hereby acknowledge notification of the privacy practices for this office.
  •  I hereby acknowledge that a copy of this practices Dental Materials Fact Sheet has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Fact Sheet.

Patient Photographic and/or Video Images Authorization

Authorization: I authorize BFD the use and disclosure of my name, photographic and/or video images, and/or testimonial/review for marketing purposes by Blatchley Family Dentistry. I understand that information disclosed pursuant to this authorization may no longer be protected by HIPAA privacy regulations and may be subject to redisclosure.

Purpose: The photographic and/or video images, as well as the testimonial and/or review, may be used by the practice for advertising, marketing, and/or social media.

Revocability: I understand that I may revoke this authorization at any time. Such revocation must be in writing. Revocation affects use and disclosure moving forward but is not retroactive. This use and disclosure authorization expires 99 years from the date of signature.

Treatment Conditions: I understand that the practice cannot condition treatment on whether I sign this authorization.

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Arbitration Agreement

BFD agrees to provide to the undersigned patient dental health care services in consideration for the payment received. By signings this arbitration clause you are agreeing to have any issues of dental malpractice decided by neutral arbitration and you are giving up your right to a jury court trial.

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