Patient Consent & Policy Agreement

Patient Information

Insurance Disclaimer

As a service to our patients, our practice accepts most dental insurance programs, including non-managed care and indemnity (traditional) plans. We are not part of any managed care network, DMO or DHMO plans. Our accounting staff will prepare all the necessary forms for your dental benefits. However, we remind you that your specific policy is an agreement between you and your insurance company. Please keep in mind that you are responsible for your total obligation should your insurance benefits result in less coverage than anticipated. Our staff will gladly submit a pre-treatment estimate to your insurance company so that you will know what your benefits will be.

The fees charged for services rendered to those who are insured are based on the contracted fees with your insurance company. Your policy may base its allowances on a fixed fee schedule, which may or may not coincide with our usual fees. You should be aware that different insurance companies vary greatly in the types of coverages available. Also, some companies take care of claims promptly, while others delay payments for several months. All co-payments must be made at time of service. Patient financing is available with approved credit with third-party vendors.

Gentle Dental Care and Georgia Dental Implant Center

Financial Policy

1. Payment is due at time of service for all services.
2. Failure to notify us at least 48 hours in advance of canceling or rescheduling an appointment may result in a BROKEN APPOINTMENT FEE of $50.00.
3. Any dishonored check will result in a $50.00 return check charge.
4. If your balance becomes 60 days delinquent, your account is subject to collections and you will be responsible for all costs associated with collecting the balance.
5. Payment options: Full payment is due at time of service unless other arrangements are made by our staff.
   We do not offer monthly payments for treatment.
   1. Cash or Check
   2. All Major Credit Cards – Visa, MasterCard, Discover, Amex
   3. Wells Fargo Health Advantage, Care Credit, and Health Credit Services: these 3rd party financing options give you convenient low monthly payment options so you can get the procedure you want now. This involves a simple one page application and immediate approval online. There are no up-front costs, no pre-payment penalties and no annual fees.
6. Insurance Cases
   1. For cases covered by insurance, all co-payments are due at time of service.
   2. It is your responsibility to confirm that our doctors participate in your insurance plan. If you see one of our doctors that is not on your plan, you are responsible for all charges in full.
   3. Insurance coverages are estimates only. You will be responsible for all charges not covered by your insurance plan.
7. Dental Records
   All dental records requests must be in writing and received 72 hours prior to the date needed. Records over 10 pages will be mailed (NOT FAXED) and an administrative fee will be assessed to cover the time and expense of reproducing the documents.
8. Surgery Cancellation Policy
   We understand that a situation may arise that could force you to reschedule, postpone, or cancel your surgery. Please understand that such changes affect not only your surgeon and staff, but other patients as well. We require a $100 appointment deposit for procedures valuing over $2000 or more than 2 hours in duration. Failure to provide us with at least 72 hours of notice when canceling or rescheduling such an appointment may result in the forfeit of your deposit. We appreciate the courtesy of notification as early as possible in order to make time available to other patients.

HIPAA Notice of Privacy Practices

Gentle Dental Care

5490 Crossroads Drive, Acworth, GA 30102
Office: 770-926-2784 Fax: 770-926-8662
www.acworthdental.com
Steve Hahn DMD, MS Gregory Donof DDS

This notice describes how your personal, dental and medical information may be used or disclosed and how you can get access to this information. Please review it carefully.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatments, payment for services and for other purposes that are permitted or required by law. It also describes your rights to access and control your PHI. Your PHI is information about you, including demographic information, that may identify you and that relates to your past, present or future oral and physical condition and related health care services.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Your PHI may be used and disclosed by your dentist, the office & clinical staff and others outside our offices that are involved in your care and treatment for the purpose of providing dental services to you, to pay your dental care bills, to support the operation of the dentist’s practice and any other uses required by law.

TREATMENT

We will use and disclose your PHI to provide, coordinate or manage your dental care or any related service. This includes the coordination or management of your dental care to a third party. For example, we would disclose your PHI, as necessary, to a third party, a dental lab, or specialty office to which you have been referred, that provides services to you. Only information that will be disclosed is that which is required to diagnose or treat you.

PAYMENTS

Your PHI will be used, as needed, to obtain payment for your dental services. Your PHI will be shared with your insurance carrier or any outside service necessary to collect payment for your dental services.

HEALTH CARE OPERATIONS

We may use or disclose, as needed, your PHI in order to support the business activities of your dental practice. These activities include, but are not limited to, quality assessment activities, employee review activities, staff training, licensing and conducting or arranging for other business activities. We may use a sign in sheet at registration where you may be asked to sign your name and indicate your doctor; we may also call your name out in the reception area when your doctor or hygienist is ready to see you. We may also use your PHI, as necessary, to contact you to remind you of your upcoming appointment(s). We may disclose your PHI in the following situations without your authorization. The situations include: as required by law, Public Health Issues, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration Requirements, Legal Proceedings, Law Enforcement, Military Activity and National Security or Worker’s Compensation. Under the law, we must disclose to you when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164-500.

PATIENT'S AUTHORIZATION TO RELEASE INFORMATION

Photo Release Consent

This form seeks consent for photographs to be taken by the Georgia Dental Implant Center, Columbia Dental Group, and Gentle Dental Care through a doctor or a representative.

By signing this form, the patient affirms in understanding that the images may be used for purposes indicated hereunder.

By consenting to the release of images, you agree that you will not receive any form of compensation in cash or in kind.

You likewise understand that your name or face will not be included in the images. Nonetheless, it is still possible that someone may still recognize you.

Your refusal to consent to the release of your photographs will not, in any way affect the care you will receive;

You may rescind your authorization to the release of the photographs by writing us a request;

I authorize the use of Photographs for the following:

• Educational purposes, such as medical procedures
• Demonstrations
• Social media and online advertising
• Print marketing and advertisements