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I affirm that the above information I have given is correct to the best of my knowledge. It will be held in confidence and it is my responsibility to inform this office of changes in the patient's medical status. I authorize the dental staff to perform all necessary dental treatment the patient may need. I understand that PD of Michigan PLLC may use and disclose pertinent health information and dental records to coordinate and manage dental care and related services to one or more health care providers or other dental specialists. I authorize the release of all information necessary to secure benefits such as obtaining reimbursement for services, confirming coverage, bill or collection activities and utilization review. I understand that I am responsible for the full balance of the account regardless of my dental benefits and directly assign Pediatric Dentistry of Michigan all insurance payments otherwise payable to me. In case of default, I agree to pay all reasonable costs and fees associated with the collection of the account balance, including by not limited to, third party collection fees, court filing fees and attorney fees. I affirm that my signature represents my agreement to all of the terms mentioned above.
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
We are required by applicable federal and state law to maintain the privacy of your child’s health information. We are also required to give you (parent, legal guardian) this Notice about our privacy practices, our legal duties, and your rights concerning your child’s health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect on April 14, 2003, 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 additional copies of this notice, please contact us using the information listed at the end of this Notice.
We use and disclose health information about your child for treatment, payment, and healthcare operations. For example:
Treatment: We may use or disclose your child’s health information to a physician or other healthcare provider providing treatment to your child.
Payment: We may use and disclose your child’s health information to obtain payment for services we provide to your child.
Healthcare Operations: We may use and disclose your child’s 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.
Your Authorization: In addition to our use of your child’s health information for treatment, payment, or healthcare operations, you may give us written authorization to use your child’s 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 was in effect. Unless you give us a written authorization, we cannot use or disclose your child’s health information for any reason except those described in this Notice.
To Your Family and Friends: We must disclose your child’s health information to you, as described in the Patient Rights section of this Notice. We may disclose your child’s health information to a family member, friend, or another person to the extent necessary to help with your child’s healthcare or with payment for your child’s healthcare, but only if you agree that we may do so.
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 child’s personal representative, or another person responsible for your child’s care, of your child’s location, your child’s general condition, or death. If you are present, then prior to use or disclosure of your child’s health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your child’s 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 child’s healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your child’s 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 will not use your child’s health information for marketing communications without your written authorization.
Required by Law: We may use or disclose your child’s health information when we are required to do so by law.
Abuse or Neglect: We may disclose your child’s health information to appropriate authorities if we reasonably believe that your child is a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your child’s health information to the extent necessary to avert a serious threat to your child’s 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 the correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.
Appointment Reminders: We may use or disclose your child’s health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).
Access: You have the right to look at or get copies of your child’s 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 child’s 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 $1.00 for each page, $25.00 per hour for staff time to locate and copy your child’s 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 child’s health information in that format. If you prefer, we will prepare a summary or an explanation of your child’s 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.)
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your child’s 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.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your child’s 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).
Alternative Communication: You have the right to request that we communicate with you about your child’s 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 a satisfactory explanation of how payments will be handled under the alternative means or location you request.
Amendment: You have the right to request that we amend your child’s 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.
Electronic Notice: 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 child’s privacy rights, or you disagree with a decision we made about access to your child’s health information or in response to a request you made to amend or restrict the use or disclosure of your child’s 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 may also 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 child’s 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.
I authorize Dr. Kim and/or dental auxiliaries of his choosing to perform upon the above-named patient the following dental treatment or oral surgery procedures(s), including the use of any necessary or advisable local anesthesia, radiographs (x-rays) or diagnostic aids.
This treatment has been explained to me, and I hereby acknowledge that the risks have been explained to me. Alternate methods of treatment, if any, have also been explained to me, as have the advantages, disadvantages and risks of each. I have had an opportunity to ask questions regarding the treatment and the risks, and that I fully understand them.
I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination. For example, root canal therapy following routine restorative procedures. I give my permission to make any/all changes and additions as necessary.
I agree to the use of local anesthesia and the use of nitrous oxide/oxygen analgesia depending on the judgement of the doctors. I understand that nitrous oxide/oxygen may occasionally produce nausea and vomiting, and all additional risks have been explained to me.
I understand and have been informed that there are possible risks and complications associated with the administration of local anesthesia, sedation and drugs. The most common of these being swelling, bleeding, pain, nausea, vomiting, bruising, tingling and numbness of the lips, gums, face and tongue, allergic reactions, hematoma (swelling or bleeding at or near the injection site), fainting, lip and cheek biting resulting in ulceration and infection of the mucosa. I also understand that there are rare potential risks such as unfavorable reactions to medications in respiratory and cardiovascular collapse (stopping or breathing and heart function) and lack of oxygen to the brain that could result in coma or death.
I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and that, therefore, there can be no guarantee either expressed or implied, as to the results of the treatment or as to the cure.
I understand that regardless of any dental insurance coverage I may have, I am responsible for payment of the dental fees. I agree to pay any attorney’s fees, or court costs, that may be incurred to satisfy this obligation.
You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.
PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION: (This includes step-parents, grandparents, and any care takers who have access to this patient's records):
In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third-party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.
The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE.
As Privacy Officer, I attempted to obtain the patient's (or representatives) signature on this Acknowledgement but did not because: