EAST PINES WEST PINES
EAST PINES WEST PINES 10021 Pines Blvd., Suite 100 Pembroke Pines, FL 33024 18503 Pines Blvd., Suite 304 Pembroke Pines, FL 33029 954.417.1337 THINGS TO KNOW PRIOR TO YOUR APPOINTMENT PARENTS/LEGAL GUARDIANS: Biological parent (or legal guardian with court papers) must be present for each visit and during the entire length of the visit. To send someone else with your child you must fill out and notarize the treatment decision assignment form (page 7). Waiting area has limited seating we kindly ask that you limit the amount of family members accompanying the patient whenever possible. Also please note that only 1 parent/legal guardian or family member is allowed to be in the operatory/clinical area with the patient. LATENESS/CANCELLATION/RESCHEDULING: We reserve the right to reschedule patients if they are not on time for their appointment–if you are running late please call us. Please give us 24 hours advanced notice to cancel or reschedule your appointment. We enforce a strict “two strike” cancel/fail policy. Any patient who cancels in less than 24 hours from their appointment time or misses an appointment (in any combination) will be dismissed as a patient from our office after the second offense. Please keep your contact information current with us. In case of an emergency we may need to reschedule your appointment. MULTIPLE INSURANCE: Patients with a Medicaid plan PLUS an HMO or PPO plan are not accepted, we are not equipped to bill multiple insurances. OPERATING HOURS: Mon: 9am–5pm | Tue: 12pm–7pm | Wed: 10am–7pm | Thu: 9am–5pm | Sat: 8:30am–1:30pm | Lunch: 1pm–2pm | Fri and Sun: CLOSED LOCATION: We are located on: the Northeast corner of Pines Blvd. and Palm Ave (NW 101st Ave) in the Pines Palm Office Park Sherwin Williams KFC Dunkin’ Donuts Bamboo Garden BP Gas MetroPCS Bank of America I HAVE READ AND UNDERSTOOD ALL PAGES CONTAINED IN THIS PACKET Name:__________________________________________ Signature:________________________________ Date:_____________ American Pediatric Dental Group © 2011 | New Patient Registration Form Page 1 of 15 EAST PINES WEST PINES 10021 Pines Blvd., Suite 100 Pembroke Pines, FL 33024 18503 Pines Blvd., Suite 304 Pembroke Pines, FL 33029 954.417.1337 NEW PATIENT REGISTRATION FORM PATIENT (CHILD’S) INFORMATION: Patient (Child’s) Name:________________________________________________________ Date of Birth:____________________ Social Security #:________________________________________________ Gender: Male Female Age:______________ School Name:________________________________________________________________________________________________ Reason for Today’s Visit:________________________________________________________________________________________ Child’s Pediatrician:_________________________________________________ Phone:_________________________________ RESPONSIBLE PARTY (PARENT OR LEGAL GUARDIAN) INFORMATION: Parent/Guardian Name:____________________________________________________ Relationship to the patient? Biological Mother Biological Father Date of Birth:_______________________ Legal Guardian/Other: ________________________ Street Address: _____________________________________ City:_____________________________ State: ___ Zip:___________ Home Phone: __________________________________________ Cell Phone: _________________________________________ Work Phone: __________________________________________ Email: ______________________________________________ Driver’s License#: _____________________________________ S.S.# ________________________________________________ Spouse Name:____________________________________________________________ Relationship to the patient? Biological Mother Biological Father Date of Birth:_______________________ Legal Guardian/Other: ________________________ Street Address: _____________________________________ City:_____________________________ State: ___ Zip:___________ Home Phone: __________________________________________ Cell Phone: _________________________________________ Work Phone: __________________________________________ Email: ______________________________________________ Driver’s License#: _____________________________________ S.S.# ________________________________________________ How would you like us to contact you? E-mail Text Message Home Phone Cell Phone Work Phone EMERGENCY CONTACT: In the event of an emergency, whom should we contact besides you? Name: _______________________________________________________________________________________________ Relationship: _________________________________________ Phone: _________________________________________ American Pediatric Dental Group © 2011 | New Patient Registration Form Page 2 of 15 PLEASE CHECK ONE OF THE FOLLOWING REFERRAL SOURCES How did you hear about us? Naidu Orthodontics Insurance Provider List Sports and Activities Weston Sports and Activities Pembroke Pines Joe DiMaggio Children’s Hospital Our City Pembroke Pines Google/Internet Search Davie Town Times Autism Notebook Cinemark/Regal Movie Theatres Franklin Charter School Nova Southeastern University Yellow Pages Yelp Montessori Pembroke Pines Pines Charter School System Facebook Twitter IF REFERRAL SOURCE IS LISTED BELOW PLEASE BE AS SPECIFIC AS POSSIBLE SO OUR OFFICE MAY PROPERLY THANK THE COMMUNITY FOR REFERRING US TO YOU! Word of Mouth / Friend ______________________________________________________(existing patient’s name) Pediatrician _________________________________________________(name of pediatrician if not listed below) Dr. Jacinth Brillante Dr. Hans Hubsch Dr. Carlos Patino Pediatric Associates location: Other Pediatric Associates location: Dr. Mario Zambrano Dolphin Pediatrics Pembroke Pines East Chapel Trail Cooper City __________________________________________________________ General Dentist/Another Pediatric Dentist ___________________________________________(name of dentist) Dental Provider in Our Office Event or Booth at Event Dr. William Peña Dr. Lizette Valiente Kids Konnection Snow Fest Other event _______________________________________ Other Referral Source ___________________________________________________________________________ American Pediatric Dental Group © 2011 | New Patient Registration Form Page 3 of 15 MEDICAL HISTORY Does your child have a history of any of the following? (Please check all that apply): NONE OF THE BELOW APPLY Heart Murmur Seizures/Epilepsy Asthma Autism Heart Disease Cerebral Palsy Sleep Apnea ADHD Sickle Cell Disease Spina Bifida Tuberculosis Psychiatric Problems Organ Transplant Down’s Syndrome Cancer/Tumors Eating Disorders Bone Marrow Transplant Diabetes Liver/Kidney Disease Drug/Alcohol Problems AIDS/HIV+ Speech/Hearing Issues GI Reflux Disease Developmental Delays Hemophilia/Thalassemia Recurrent Ear Infections Cystic Fibrosis Mental Retardation Blood Transfusions/Dialysis Abnormal bleeding Visual/hearing impaired Rheumatic Fever Other___________________________________________________________________ Elaborate on checked items:_____________________________________________________________________________________ Optional: Race:___________________________________ Language: _______________________________________________ NO KNOWN ALLERGIES Does your child have any allergies to the following? Latex Penicillin Medications: _________________________________________________________________________ Food/Other: ______________________________________________________________________________________________ NO MEDICATIONS TAKEN Does your child take any medications? Yes, please list: ____________________________________________________________________________________________ NEVER BEEN HOSPITALIZED Has your child ever been hospitalized or had surgeries? Yes, please specify: _________________________________________________________________________________________ DENTAL HISTORY Is this your child’s first visit to a dentist? Yes NO, my child was at a dentist on the following date: ______________________ How many times per day does your child BRUSH his/her teeth? 0 1 2 ≥3 How many times per day does your child FLOSS his/her teeth? 0 1 2 ≥3 Adult Supervision? Yes Adult Supervision? Yes No No NO PAST TRAUMA/INJURIES Has your child ever had any trauma or injuries to the mouth or teeth? Yes, please specify: _________________________________________________________________________________________ NO DENTAL PAIN Does your child currently have any dental pain? Yes, please specify: _________________________________________________________________________________________ NO PAST PAIN/INFECTION Has your child had dental pain/infection in the past? Yes, please specify: _________________________________________________________________________________________ NONE OF THE BELOW APPLY Does your child have any of the following habits? Thumb/Finger Sucking Lip Biting/Sucking Teeth Grinding/Clenching Pacifier Use Mouth Breathing Snores while sleeping Nail Biting Protrudes Tongue Does your child fall asleep with the bottle or sippy cup in his/her mouth? NO BOTTLE/SIPPY CUP WHEN SLEEPING Yes, please specify: _________________________________________________________________________________________ American Pediatric Dental Group © 2011 | New Patient Registration Form Page 4 of 15 INSURANCE INFORMATION: NOTE: WE DO NOT BILL MULTIPLE INSURANCES Do you have insurance coverage for your child? Yes No I have already provided you with this information (if so, please read below, sign and date and move on to the next page) Policy Owner Name:_________________________________________________ Date of Birth:_______________________ Insurance Company:____________________________________________________________________________________ Policy #:__________________________________________________________ Group#:____________________________ Insurance Company Address:_____________________________________________________________________________ City:______________ ____________________________________________________ State: _____ Zip:_______________ Insurance Company Telephone:___________________________________________________________________________ FOR PATIENTS WITH DENTAL INSURANCE: I understand that the American Pediatric Dental Group uses all resources available to them to verify my insurance however those resources do no provide a guarantee of payment. All claim payments are determined at the time of claim submission. Furthermore I certify that my child is covered by the above named insurance company and I assign directly to the American Pediatric Dental Group all insurance benefits otherwise payable to me. I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductible that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature and all my insurance submissions, whether manual or electronic. Should the account be referred to any attorney for collection, the undersigned shall pay reasonable attorney’s fees and expenses. PLEASE NOTE: Payment in full is expected at the time of dental treatment. The parent or guardian who accompanies the child is responsible for payment at time of service unless prior arrangements have been made. Since we reserve a special time to offer quality treatment for your child, patients with two or more broken or cancelled appointments without a minimum 24 hour notice will result in discontinuation of any further dental services, except for 30 days of dental emergencies. I affirm that all the information that I have given in these 5 pages is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child’s medical status. I authorize the dental staff to perform the necessary dental services my child may need. ____________________________________________________________________________ SIGNATURE OF PARENT OR GUARDIAN American Pediatric Dental Group © 2011 | New Patient Registration Form _____________________ DATE Page 5 of 15 ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES VERY IMPORTANT: YOU MUST COMPLETELY READ THE APDG HIPPA NOTICE OF PRIVACY PRACTICES BEFORE SIGNING THIS ACKNOWLEDGEMENT FORM! I have legal authority for this child and acknowledge that I have received AND reviewed my copy of American Pediatric Dental Group's HIPAA Notice of Privacy Practices. Print Name of Parent or Legal Guardian Parent/Legal Guardian’s Signature Date (if you are the parent print, sign and date here only) If you are the personal representative please state your relationship to the patient that gives you authority over him/her: Power of Attorney Other: ___________________________________________________________ Personal Representative ’s Signature OR Print Name of Personal Representative Date Please Note: It is your right to refuse to sign this Acknowledgement. ******Dental Office Use Only****** I tried to obtain written Acknowledgement by the individual noted above of receipt of our Notice of Privacy Practices, but it could not be obtained because: An emergency prevented us from obtaining acknowledgement. A communication barrier prevented us from obtaining acknowledgement. The individual was unwilling to sign. Other:_____________________________________________________________ Print Name of Staff Member Staff Member’s Signature American Pediatric Dental Group © 2011 | New Patient Registration Form Date Page 6 of 15 IN ORDER TO SEND SOMEONE ELSE WITH YOUR CHILD YOU MUST FILL OUT AND NOTARIZE THIS FORM OR WE WON’T BE ABLE TO SEE YOUR CHILD! PAGE 7: TREATMENT DECISION ASSIGNMENT Patient Chart Number(s) Patient Name(s) Date Of Consent This is to document that I, Print Parent/Legal Guardian’s Name give complete permission to Print Assignee’s Name in making all necessary treatment decisions for the care of my child(ren), Print Child(ren)’s Name(s) Thank you. Parent/Legal Guardian’s Signature Date Assignee’s Signature Date Print Notary’s Name Notary’s Signature NOTARY SEAL MUST BE NOTARIZED OR NOT VALID! American Pediatric Dental Group © 2011 | New Patient Registration Form Date Page 7 of 15 Your child is in need of some basic dental care. This form explains the care that your child needs, and requests your permission to provide that care. CONSENT FOR GENERAL PROCEDURES FOR FIRST AND FUTURE VISITS Prophylaxis (Cleaning) and Topical Fluoride Treatment: A licensed health professional will be cleaning and applying fluoride to your child’s teeth as a means of preventing tooth decay (cavities). Fluoride is applied topically to the teeth in the form of a gel or varnish after the cleaning. The fluoride helps strengthen the teeth and prevent tooth decay. Dental Radiographs: The use of dental radiographs, or x-rays, allows the doctor to detect dental problems early before serious damage is done to your child’s teeth, gums, and supporting bones and structures. If these conditions are not detected until there are visible or painful signs of disease, your child’s oral health can be seriously affected. Dental radiographs are a part of a comprehensive dental oral examination. We may not be able to complete a comprehensive exam without the use of x-rays. Dental Fillings: Decay dissolves the tooth, and if not treated, will result in an abscessed tooth causing pain and infection. The dentist will remove the decayed and weakened part of the tooth and replace it with a resin-based material to strengthen the tooth. A local anesthetic may be used that will "numb" the area being treated for one or two hours. Sealants: Back teeth have grooves and pits in which decay usually starts. The dentist or hygienist will "seal" the grooves with a plastic coating to help prevent the decay from starting. No anesthetic is needed. PROCEDUES WHERE CONSENT IS REQUESTED AS NECESSARY: Stainless Steel Crowns: If a tooth is badly destroyed by decay, a filling will not stay in place. Therefore, a tooth is trimmed around the sides and a preformed crown or "cap" is placed over the tooth to protect it from breaking. As with fillings, the area is usually treated with an anesthetic to help the child remain comfortable for one to two hours. Nerve or Pulp Treatment: When the decay or infection progresses far enough that the tissue inside the tooth is infected, all or part of that infected tissue must be removed and a special filling placed in order to keep the infection from spreading to other parts of the body. The treatment may take at least two visits during which an anesthetic will be used. Pain or swelling after this work is rare and usually minor. Antibiotics may be used to control possible infections. After treatment, a filling or crown will be placed to help strengthen the tooth and keep it from breaking. Extraction or Removal of the Tooth: If the infection has spread too far to rebuild the tooth, it is often best to remove the tooth to prevent infection from spreading. After "numbing" the area with anesthetics, the tooth is removed and the area packed with gauze to control bleeding. Care should be taken not to rinse for a couple of days or bleeding may begin again. Biting on gauze or towels will usually stop the bleeding. Pain or swelling after this work is rare and usually minor. Behavior Management Techniques: In order to successfully complete your child’s dental treatment the dentist and staff may need to use techniques such as: Voice Control, Distraction, Tell-Show-Do, Positive Reinforcement, and Parental presence/absence. Furthermore, the use of a “mouth prop” may be needed in order to maintain your child’s mouth open during treatment. In certain cases, the use of physical restraint (papoose board) may be needed to maintain the safety of your child during treatment. Nitrous Oxide and/or Premedication: If a child is particularly nervous about dental treatment, the dentist may use "laughing gas" (nitrous oxide) or some other medication to help relax the child so the work can be done properly. The medications may cause the child to be drowsy after the appointment. American Pediatric Dental Group © 2011 | New Patient Registration Form Page 8 of 15 1. I understand that my child may need to receive one or more of the dental services listed and explained above from American Pediatric Dental Group™. 2. I understand that none of the additional consent procedures will be performed without discussing the necessity with me and obtaining my consent to proceed. I am advised that good results are expected; however, the possibility of complications cannot be accurately anticipated. Therefore, no guarantee, expressed or implied, can be given to me regarding this treatment. 3. I fully understand and authorize the doctor to perform any necessary treatment that in his/her judgment will be in the best interest of my child’s health, once treatment has begun. Although their occurrence is rare and unpredictable, some risks are known to be associated with dental or oral surgical procedures, medication, and/or anesthetics. We are required to disclose the known risks of numbness, infection, aspiration (swallowing), swelling, bleeding, discoloration, nausea, vomiting, allergic reaction, and scarring. I understand and accept that complications may require medical assistance and hospitalization. 4. I also understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the gums or teeth that were not discovered during examination. The most common being the need for nerve (pulp) therapy or extraction following routine restorative procedures. I give my permission to the dentist to make any/all changes and additions as necessary. 5. I understand that Dr. William A. Peña is an adjunct faculty at Nova Southeastern University College of Dental Medicine (a teaching facility) and occasionally may have dental residents/students observe during your child’s consultation, examination, and/or treatment. 6. I UNDERSTAND THAT PHOTOGRAPHS AND LIVE VIDEO RECORDING ARE USED TO DOCUMENT AND ASSIST WITH MY CHILD’S CARE. These images may be used for insurance claim submittal. These images and videos may also be used for educational purposes in study club meetings, lectures, seminars, demonstrations, and professional publications (journals, magazines). If the photographs or any digital recordings are used in any publication or as a part of a demonstration, my child’s name or other identifying information will be kept confidential. PARENTS/LEGAL GUARDIANS: Due to HIPPA, parents (or legal guardian) must be present for each visit and during the entire visit. Legal Guardians must bring in court papers to verify guardianship. If you want to send your child with another adult over 18 you must fill out a Treatment Decision Assignment form and have it notarized (page 6 of the online packet or you can get one emailed/faxed from us). Please keep your contact information current with us. American Pediatric Dental Group © 2011 | New Patient Registration Form Page 9 of 15 LATENESS: We enforce a strict lateness policy but we will work with you to keep your appointment providing you call us. Late arrivals will result in longer wait times to accommodate you into the schedule. We reserve the right to reschedule patients if necessary (no show will result in a strike). Lateness of two or more consecutive times will result in a strike. LAST MINUTE CANCELLATIONS/STRIKES/PATIENT DISMISSAL: Please allow us at least 24 hours to cancel or reschedule your appointment. We enforce a strict cancellation/fail policy. Each cancellation of less than 24 hours or no show will get a strike on the child’s account. Lateness of two or more consecutive times will result in a strike. After 2 strikes your child will be dismissed as a patient from our office. Due to high demand for Saturdays, any last minute cancellation or no show will result in not being able to have another Saturday appointment for 3 months. When leaving a voicemail if the time/date stamp on your message is 24 hours or more before your appointment you will not receive a strike. OTHER OFFICE POLICIES: Our office considers respect for all its staff and patients of paramount importance. Individuals who intentionally act in a disrespectful manner will result in immediate dismissal from our office. Dentistry in caring hands is more than a tagline. We take the time to treat children who are apprehensive which may cause appointments to back up but we always strive to see all patients at their appointed time. No eating/drinking permitted inside our practice. Any patient with an after-hour emergency may go to the nearest emergency room but we recommend: 1005 Joe DiMaggio Drive | Hollywood, FL 33021 | 866-532-4362 Please note that this form will be signed in our office. American Pediatric Dental Group © 2011 | New Patient Registration Form Page 10 of 15 HIPAA Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. I. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION American Pediatric Dental Group (APDG) may use your protected health information for purposes of providing treatment, obtaining payment for treatment, and conducting health care operations. Your protected health information may be used or disclosed only for these purposes unless APDG has obtained your authorization or the use or disclosure is otherwise permitted by the HIPAA Privacy Regulations or State law. Disclosures of your protected health information for the purposes described in this Notice may be made in writing, orally, or by facsimile. Communications to you may be made by mail, facsimile, or by telephone. For example, APDG may communicate to you by leaving messages on your answering machine. A. 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 treatment purposes. For example, we may disclose your protected health information to a pharmacy to fulfill a prescription, to a laboratory to order a blood test, or to a home health agency that is providing care in your home. We may also disclose protected health information to other physicians who may be treating you or consulting with your physician with respect to your care. In some cases, we may also disclose your protected health information to an outside treatment provider for purposes of the treatment activities of the other provider. B. Payment. Your protected health information will be used, as needed, to bill and collect payment for your health care services. This may include certain communications to your health insurer to get approval for the treatment that we recommend. For example, if a hospital admission is recommended, we may need to disclose information to your health insurer to get prior approval for the hospitalization. We may also disclose protected health information to your insurance company to determine whether you are eligible for benefits or whether a particular service is covered under your health plan. In order to get payment for your services, we may also need to disclose your protected health information to your insurance company to demonstrate the medical necessity of the services, or as required by your insurance company, for utilization review. We may also disclose patient information to another provider involved in your care for the other provider’s payment activities. We may release information to an outside agency for collection purposes. C. Operations. We may use or disclose your protected health information, as necessary, for our own health care operations in order to facilitate the function of APDG and to provide quality care to all patients. Health care operations include such activities as: • Quality assessment and improvement activities • Employee review activities • Training programs including those in which students, trainees, or practitioners in health care learn under supervision • Accreditation, certification, licensing, or credentialing activities • Review and auditing, including compliance reviews, medical reviews, legal services, and maintaining compliance programs • Business management and general administrative activities American Pediatric Dental Group Notice of Privacy Practices Page 11 of 15 In certain situations, we may also disclose patient information to another provider or health plan for their health care operations. D. Other Uses and Disclosures. As part of treatment, payment, and health care operations, we may also use or disclose your protected health information for the following purposes: • To remind you of an appointment (Please note that appointment reminders may be communicated by snail mail, e-mail, text or by leaving a message on the answering machine of a telephone number that you have provided.) • To inform you of potential treatment alternatives or options • To inform you of health-related benefits or services that may be of interest to you II. USES AND DISCLOSURES BEYOND TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS PERMITTED WITHOUT AUTHORIZATION OR OPPORTUNITY TO OBJECT Federal privacy rules allow us to use or disclose your protected health information without your permission or authorization for a number of reasons including the following: A. When Legally Required. We will disclose your protected health information when we are required to do so by any Federal, State or local law. B. When There Are Risks to Public Health. We may disclose your protected health information for the following public activities and purposes: • To prevent, control, or report disease, injury, or disability as permitted by law • To report vital events such as birth or death as permitted or required by law • To conduct public health surveillance, investigations, and interventions as permitted or required by law • To collect or report adverse events and product defects; track FDA-regulated products; and enable product recalls, repairs, or replacements to the FDA and conduct post-marketing surveillance • To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease as authorized by law • To report to an employer information about an individual who is a member of the workforce as legally permitted or required C. To Report Abuse, Neglect, or Domestic Violence. We may notify government authorities if we believe that a patient is the victim of abuse, neglect, or domestic violence. It is the responsibility of any/all personnel to alert the proper authorities in the event a minor, elderly, or vulnerable adult patient is identified as a victim of alleged or suspected neglect or abuse including sexual abuse, and to comply with proper procedures for the reporting as required or authorized by law. D. To Conduct Health Oversight Activities. We may disclose your protected health information to a health oversight agency for activities including audits; civil, administrative, or criminal investigations, proceedings, or actions; inspections; licensure or disciplinary actions; or other activities necessary for appropriate oversight as authorized by law. We will not disclose your health information if you are the subject of an investigation and your health information is not directly related to your receipt of health care or public benefits. E. In Connection with Judicial and Administrative Proceedings. We may disclose your protected health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena if you have been notified of the request for information. American Pediatric Dental Group Notice of Privacy Practices Page 12 of 15 F. For Law Enforcement Purposes. We may disclose your protected health information to a law enforcement official for law enforcement purposes as follows: • As required by law for reporting of a gunshot wound or life threatening injury indicating an act of violence • Pursuant to court order, court-ordered warrant, subpoena, summons or similar process • For the purpose of identifying or locating a suspect, fugitive, material witness, or missing person • Under certain limited circumstances, when you are the victim of a crime • To a law enforcement official if APDG has a suspicion that your death was the result of criminal conduct • In an emergency in order to report a crime • In the event a minor, elderly, or vulnerable adult patient is identified as a victim of alleged or suspected neglect or abuse including sexual abuse G. To Coroners, Funeral Directors, and for Organ Donation. We may disclose protected health information to a coroner or medical examiner for identification purposes, to determine cause of death, or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out his or her duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye, or tissue donation purposes. H. For Research Purposes. We may use or disclose your protected health information for research without your authorization in limited circumstances only if the use or disclosure for research has been approved by an institutional review board or privacy board that has reviewed the research proposal and research protocols and decided that your information is necessary to the research and the privacy of your information will be protected. I. In the Event of a Serious Threat to Health or Safety. We may, consistent with applicable law and ethical standards of conduct, use or disclose your protected health information if we believe, in good faith, that such use or disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public. J. For Specified Government Functions. In certain circumstances, the Federal regulations authorize APDG to use or disclose your protected health information to facilitate specified government functions relating to military and veterans activities, national security and intelligence activities, protective services for the President and others, medical suitability determinations, correctional institutions, and law enforcement custodial situations. K. For Worker's Compensation. We may release your health information to comply with worker's compensation laws or similar programs. III. USES AND DISCLOSURES PERMITTED WITHOUT AUTHORIZATION, BUT WITH OPPORTUNITY TO OBJECT We may disclose your protected health information to your family member(s) or a close personal friend if it is directly relevant to the person’s involvement in your care or payment related to your care. We can also disclose your information in connection with trying to locate or notify family member(s) or others involved in your care concerning your location, condition, or death. You may object to these disclosures. If you do not object to these disclosures or we can infer from the circumstances that you do not object or we determine, in the exercise of our professional judgment, that it is in your best interests for us to make disclosure of information that is directly relevant to the person’s involvement with your care, we may disclose your protected health information as described. IV. USES AND DISCLOSURES WHICH YOU AUTHORIZE Other than as stated above, we will not disclose your health information other than with your written authorization. You may revoke your authorization in writing at any time except to the extent that we have taken action in reliance upon the authorization. American Pediatric Dental Group Notice of Privacy Practices Page 13 of 15 V. YOUR RIGHTS You have the following rights regarding your health information: A. The Right to Inspect and Copy Your Protected Health Information. You may inspect and obtain a copy of your protected health information that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that are used to make decisions about you. Under Federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to a law that prohibits access to protected health information. Depending on the circumstances, you may have the right to have a decision to deny access reviewed. We may deny your request to inspect or copy your protected health information if, in our professional judgment, we determine that the access requested is likely to endanger your life or safety or that of another person, or that it is likely to cause substantial harm to another person referenced within the information. You have the right to request a review of this decision. To inspect or copy your medical information, you must submit a written request to the APDG office where you received services and direct the correspondence to the Privacy Contact. The contact information for that the APDG office is attached to this Notice. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing, or other costs incurred by us in complying with your request. Please contact our Privacy Officer (General Manger) if you have questions about access to your medical record. B. The Right to Request a Restriction on Uses and Disclosures of Your Protected Health Information. You may ask us, in writing, not to use or disclose certain parts of your protected health information for the purposes of treatment, payment, or health care operations. You may also request, in writing, that we not disclose your health information 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. APDG is not required to agree to a restriction that you may request. We will notify you in writing if we deny your request for a facility directory, disclosures to friends or family members involved in your care, or certain other disclosures we are permitted to make without your authorization. The request for an accounting must be made, in writing, to the Privacy Contact at the APDG office where you received services. The request should specify the time period sought for the accounting. We are not required to provide an accounting for disclosures that take place prior to April 14, 2003. Accounting requests may not be made for periods of time in excess of six years. We will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee. E. The Right to Obtain a Paper Copy of This Notice. Upon request, we will provide a separate paper copy of this notice even if you have already received a copy of the notice or have agreed to accept this notice electronically. VI. OUR DUTIES APDG is required by law to maintain the privacy of your health information and to provide you with this Notice of our duties and privacy practices. We are required to abide by terms of this Notice as may be amended from time to time. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all protected health information that we maintain. If APDG changes its Notice, we will provide a copy of the revised Notice on your next office visit to APDG. VII. COMPLAINTS You have the right to express complaints to APDG and to the Secretary of Health and Human Services if you believe that your privacy rights have been violated. You may complain to APDG by contacting in writing the Privacy Contact at the APDG office where you received services. We encourage you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint. American Pediatric Dental Group Notice of Privacy Practices Page 14 of 15 VIII. EFFECTIVE DATE This Notice is effective April 14, 2003. to a restriction. If APDG does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. Under certain circumstances, we may terminate our agreement to a restriction. You may request, in writing, a restriction by contacting the Privacy Contact at the APDG office where you received services. C. The Right to Request to Receive Confidential Communications from Us by Alternative Means or at an Alternative Location. You have the right to request that we communicate with you in certain ways. We will accommodate reasonable requests. We may condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not require you to provide an explanation for your request. Requests must be made, in writing, to the Privacy Contact at the APDG office where you received services. D. The Right to Request Amendment of Your Protected Health Information. You may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. If you believe that there is a mistake or missing information in our record of your protected health information, you may request, in writing, that we correct or add to the record. In this written request, you must also provide a reason to support the requested amendment. We will respond within 60 days of receiving your request. We may deny the request if we determine that the protected health information is: (1) correct and complete; (2) not created by us and/or not part of our records, or; (3) not permitted to be disclosed. Any denial will state the reasons for denial and explain your rights to have the request and denial, along with any statement in response that you provide, appended to your protected health information. If we approve the request for amendment, we will change the protected health information and so inform you. Requests for amendment must be directed to the Privacy Contact at the APDG office where you received services. E. The Right to Receive an Accounting. You have the right to request, in writing, an accounting of certain disclosures of your protected health information made by APDG. This right applies to disclosures for purposes other than treatment, payment, or health care operations as described in this Notice of Privacy Practices. We are also not required to account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, disclosures American Pediatric Dental Group Notice of Privacy Practices Page 15 of 15
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