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TERMS & CONDITIONS

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

For Treatment We may use your health information to provide you with medical treatment or services. We may
disclose health information about you to doctors, dental assistants, technicians, office staff or other personnel who
are involved in taking care of you and your health.

For example, your doctor may be performing a tooth extraction and may need to know if you have other health
problems that could complicate your treatment. The doctor may use your health history to decide what treatment
is best for you. The doctor may also tell another doctor about your condition so that doctor can help determine the
most appropriate care for you.

Different personnel in our office may share information about you and disclose information to people who do not
work in our office in order to coordinate your care, such as phoning in prescriptions to your pharmacy, scheduling
lab work and ordering x-rays. Family members and other health care providers may be part of your medical care
outside this office and may require information about you that we have.

For Payment We may use and disclose health information about you so that the treatment and services you
receive at this office may be billed to and payment may be collected from you, an insurance company or a third
party. For example, we may need to give your health plan information about a service you received here so your
health plan will pay us or reimburse you for the service. We may also tell your health plan about a treatment you are
going to receive to obtain prior approval, or to determine whether your plan will cover the treatment.

For Health Care Operations We may use and disclose health information about you in order to run the office and
make sure that you and our other patients receive quality care. For example, we may use your health information to
evaluate the performance of our staff in caring for you. We may also use health information about all or many of our
patients to help us decide what additional services we should offer, how we can become more efficient, or whether
certain new treatments are effective.

Appointment Reminders We may contact you as a reminder that you have an appointment for treatment or
medical care at the office.

Treatment Alternatives We may tell you about or recommend possible treatment options or alternatives that may
be of interest to you.

Health-Related Products and Services We may tell you about health-related products or services that may be of
interest to you.

TESTIMONIALS

I wish all of my dental experiences were like this! From the front desk to my actual procedure, I felt comfortable and more than pleased with my experience at the office. It was cool to look at the great views during my procedure. It made the time go by so quickly. The staff, the office, the procedure-all superb.

Rodney Franks

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Download pdf form, print it out, and bring it to the appointment already pre-filled with your personal information.

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