Stellar Smile Center

NOTICE OF PRIVACY POLICIES FOR OFFICES OF STELLAR SMILE CENTER.

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAYBE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Introduction:
At Stellar Smile Center office, we are committed to treating and using protected health information about you in a responsible manner. This Notice of Health Information Practices describes the personal information we collect, and how and when we may use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effective 04/04/03 and applies to all protected health information as defined by Federal regulations.

Understanding Your Health Record Information:
Each time you visit Stellar Smile Center office. a record of your visit is made. Typically. this record contains your symptoms. examination and test results. diagnosis. treatment. and a plan for future care or treatment. This information. often referred to as your health. dental. or medical record. serves as a: *Basis for planning your care or treatment. *Means of communication among the many health professionals who contribute to your care,

Your Health Information Rights:
Although your health record is the physical property of the offices of Stellar Smile Center, the information belongs to you. You have the right to: *Obtain a paper copy of this notice of information practices upon request, *Inspect and copy your health record as provided for in 45 CFR 164,524, *Amend your health record as provided in 45CFR 164, 528, *Obtain an accounting of disclosures of your health information as provided in 45 CFR 164, 528,

*Request communication of your health information by alternative means or at alternative locations, *Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164. 522. and *Revoke your authorization to use or disclose health information except to the extent that action has already been taken

Our Responsibilities:
The offices of Stellar Smile Center are required 'to: *Maintain the privacy of your health information. *Provide you with this notice as to our legal duties and privacy practices with respect to information we could and maintain about you.

*Abide by the terms of this notice. *Notify you if we are unable to agree to a requested restriction, and,

*Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations. We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you have supplied to us, or if you agree. we will email the revised notice to you.

We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue to use or disclose your health information after we have received a written revocation of the authorization according to the procedures included in the authorization.

For More Information or to Report a Problem:
If you have questions and would like additional information, you may contact the Privacy Officer of our office at 973·339·9711. If you believe your privacy rights have been violated, you can file a complaint with the practice's Privacy Officer. or with the Office of Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint. The address for the OCR is: Office of Civil Rights, U>S> Department of Health and Human Services, 200 Independence Avenue. SW. Room 509F. HHH Building, Washington. DC 20201.

Disclosure for Treatment, Payment and Health Operations:
We will use your health information for treatment. We will use your health information for payment. We will use your health information for regular health operations.

Business Associates: We may disclose health infonnation to our business associates so that they can perfonn the job that we ask them to do. We require these associates to appropriately safeguard your infonnation.

Notification: We may use or disclose infonnation to notity a family member, personal representative or another person responsible for your care. your location. and general condition.

Communication: Health professionals, using their best judgement, may disclose to a family member, other close relative. personal friend. or any other person you identity. health infonnation relevant to your care. or payment related to your care

Research: We may disclose infonnation to researchers when their research has been approved by an institutional review board that has reviewed the proposal and established protocols to ensure the privacy of your health infonnation.

Marketing: We may contact you to provide appointment reminders or infonnation about treatment alternatives. or other health-related benefits and services that may be of interest to you. We routinely use telephone, fax, and mail for such contacts if you do not wish to receive these types of communications please advise us.

Food and Drug Administration (FDA): We may disclose to the FDA any health infonnation relative to adverse events with respect to products and product defects in order to enable recalls. repairs, or replacement.

Workers Compensation: We may disclose health infonnation to the extent authorized by. and to the extent required to comply with the law.

Public Health: As required by law. we may disclose your health infonnation to public health or legal authorities charge with preventing or controlling disease, injury, or disability.

Law Enforcement: We may disclose health infonnation for law enforcement purposes as required by law, or in response to a valid Subpoena.

Federal law makes provisions for your health infonnation to be released to an appropriate health oversight agency. public health authority. or attorney provided that a work force member, or business associate, believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients. workers. or the public.


Written Financial Policy Thank you for choosing Stellar Smile Center. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.

Payment Options:
You can choose from:
- Cash, Check, Visa, Mastercard, American Express or Discover Card
We offer a 5% courtesy accounting adjustment to patients who pay for their treatment with cash prior to completion of care for treatment plans of $1500 or more. - NO INTEREST1 Payment Plans2 from CareCredit

Please note:
Stellar Smile Center requires payment prior to the beginning of your treatment.
Any open accounts that are not paid within 14 days are subject to a collection agency fee of 35% which is payable by the guarantor on the account.
For plans requiring multiple appointments, alternative payment arrangements may be provided. For larger, more comprehensive treatment plans of $2000 or more, a 10% deposit is required to secure your initial treatment appointment.
For patients with dental insurance we are happy to work with your carrier to maximize your benefit and provide you with the documentation you need to receive reimbursement for your treatment.
A fee of $50 is charged for patients who miss or cancel more than 1 time in a calendar year without 48-hour notice.
Stellar Smile Center charges $35 for returned checks.
If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need.

Consent

I have discussed with my dentist and or office staff the restorative options available to me. I understand that my insurance company has an allowance for BASIC materials used in restorative procedures and that my provider can not balance bill for the basic materials. I understand that a Cerec Restoration is kinder to natural teeth than traditional porcelain. After discussing the available options, I have decided to upgrade the material types being used and agree to pay the difference in cost to the amount my insurance company allows.

All questions regarding restorative options and additional costs involved have been answered by my dentist and are understood by me.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

(You May Refuse to Sign This Acknowledgement*)

The undersigned has received a copy of the Office's Notice of Privacy Practices.

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