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Thank
you for being a patient at our office. We pride ourselves in offering
individualized, preventive dental treatment for family members of
all ages. Please take a moment to read this information, which outlines
the services, hours, expectations, and policies of this office.
OFFICE
HOURS
Our
management and clerical staff are available:
Mondays, 9:00 to 2:00
Tuesday, Wednesday, Thursday from 8:00 to 5:00
Fridays, 8:00 to 2:00
PATIENT
HOURS
Dr. Anzelc and her hygienists treat patients:
Tuesday 9:00 - 5:00
Wednesday 9:00- 5:00
Thursday 9:00 - 5:00
Friday 9:00 - 2:00
TELEPHONE CALLS
You
are encouraged to call with any questions you have. Your inquiry
will be directed to the person whom can best help you. The staff
is well qualified to answer most questions, but if the call requires
you to speak with the doctor, she will return your call at the earliest
opportunity.
If
at anytime you have questions regarding treatment, fees or services,
please discuss them with us promptly and frankly. We will make every
effort to resolve the matter in a way ameniable to all parties.
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EMERGENCY
CARE
Should
a dental emergency arise, we do our best to respond to your problem
promptly. Please call us as early as possible in the day for a scheduled
appointment. If the problem occurs after hours, you will reach our
answering service. They will direct your call accordingly or you
may leave a private voice mail message and you will be called on
our next business day. PLEASE NOTE: If the emergency includes severe
pain, severe swelling, high fever or excessive bleeding, go to the
emergency room.
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LATE
ARRIVALS, LATE CANCELLATIONS, FAILURE TO SHOW & IRREGULAR CARE
We
see you on an appointment basis and make every effort to be timely.
We request you extend the same courtesy to us. If you are unable
to keep an appointment, we request TWO BUSINESS DAYS notice. Our
office number reaches a 24-hour, private, voice mail system, so
leaving your cancellation message may be done at any hour. Cancellations
with less than two business days notice, or failure to show for
an appointment, may result in a charge of $25 per half hour of scheduled
time.
If
we know we are running late due to an emergency or unforeseen circumstances,
we make every effort to contact those patients whose appointments
will be affected. Please allow some cushion in your schedule for
any appointment in case we run late. All patients are given the
time they need when in the chair and it may not be exactly as scheduled.
Similarly, we respectfully request that our patients let us know
if they are going to be late so we may determine if we can still
keep the appointment. Patients arriving 10 minutes late without
prior notice may be asked to reschedule.
We
do maintain a record of late cancellations and failures to show
for appointments. When any patient has late cancelled or failed
2 appointments, their file is reviewed and we reserve the right
to ask the patient to find another provider.
We
also track and flag patients who have not appointed within the past
two years. Patient charts are inactivated at that time.
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EXCHANGE
OF INFORMATION
During
your initial conversation with this office, you were asked the name
of your previous provider so we could obtain available x-rays (please
note that initially only films are exchanged).
Should
you find yourself in the position of leaving this office, you will
receive a Permission to Release form requiring your signature. Upon
its return to our office, your x-rays will be duplicated and forwarded
to your new dentist. We follow the procedure accepted by the Maine
Dental association, which is:
1.
Originals are kept in the treating dentist's file. Treatment records,
including radiographs, should be duplicated and only the duplicates
released.
2. All requests for records should be in writing from the patient
or guardian.
3. Copies of records may not be withheld because of an outstanding
bill with the dental office.
4. A fee may be charged for duplicating and mailing.
5. Copies must be released to the authorized representative within
a "reasonable time", although this time is not defined
in the law.
6. Please note: a copy of the Maine law may be obtained from the
MDA Central Office or from the State
of Maine web site: http://janus.state.me.us/legis/statutes/22/title22ch4010sec1711-A.html
There
is no charge for the duplication unless your account has a balance
or we are forwarding the films directly to you, in which case a
$25 fee per person will be assessed. This fee must be received in
full before any films are released.
If
your new dentist calls requesting the written records, they will
be copied and forwarded if you have indicated permission to do so.
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PAYMENT
POLICY *
Payment
is due on the day services are provided. Please choose one of the
following means of remittance:
Cash,
Check, Debit Card, MasterCard, VISA, Discover or American Express
Returned
checks will be charged a $25.00 fee.
Before
The Services Are Rendered:
For
your own peace of mind, you may wish to have a treatment plan detailing
the advised treatment, fees and your estimated out of pocket responsibility.
Please ask the front desk for a detailed treatment plan if desired.
Our office provides you with that estimate at no charge. Further,
if you have insurance, the treatment plan can be sent to your insurance
company for THEIR written estimate of benefits. Obtaining this estimate
from your insurance company will not obligate you to the treatment.
Insurance:
You
are responsible for understanding your own insurance and benefits.
Your policy is an agreement between you and the insurance company.
You are responsible for payment of services rendered to you. The
insurance company is responsible to you. You may choose to pay in
full and have the insurance benefit remitted directly to you.
If
you do not pay in full, YOU ARE RESPONSIBLE FOR YOUR CO-PAYMENT
AND/OR DEDUCTIBLE ON THE DAY THE SERVICE IS PROVIDED. The co-payment
requested is an Estimate. Insurance policies vary greatly in allowable
benefits. If a balance remains after the insurance has paid its
portion, you will be billed. If you have overpaid your co-payment,
a refund check will be mailed to you promptly. Please be aware that
some companies pay a fixed allowance for certain procedures and
others pay a percentage of the charge.
The
office submits all claims the next business day when they have been
reviewed. Please realize that professional services are rendered
to a person, not to an insurance company. Ultimately, you are financially
responsible to us and the insurance company is responsible to you.
If there are problems, we will help in any way we can, but if an
insurance company's portion remains unpaid for more than 60 days,
you will be expected to pay that balance in full.
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Who
Is Responsible:
The
patient is responsible for his or her payment. If the patient is
a minor and has been brought by an adult, the accompanying adult
is responsible for payment. If a young adult has been sent on his
or her own, the parent or guardian needs to make arrangements for
payment. Please call ahead with a credit/debit card number or give
the patient a blank check.
Sometimes,
in the case of a divorce, one parent has been designated by the
courts to be responsible for the child's expenses. Payment is the
responsibility of the parent or guardian who brings the child to
the appointment and it is that parent's responsibility to collect
reimbursement.
Finance Charges
Should
a balance remain outstanding for more than thirty days, a finance
charge will be assessed. The rate is 18% per annum (1.83%/month).
A finance charge is not assessed on any portion of a balance due
from an insurance company.
*This
policy is subject to change without notice.
Notice
Of Privacy Practices
Purpose:
This form, Notice of Privacy Practices, presents the information
that federal law requires us to give our patients regarding our
privacy practices. {Note: this form may need to be changed to reflect
the dental practice's particular privacy policies and/or stricter
state laws.}
We must provide this Notice to each patient beginning no later than
the date of our first service delivery to the patient, including
service delivered electronically, after April 14, 2003. We must
make a good-faith attempt to obtain written acknowledgement of receipt
of the Notice from the patient. We must also have the Notice available
at the office for patients to request to take with them. We must
post the Notice in our office in a clear and prominent location
where it is reasonable to expect any patients seeking service from
us to be able to read the Notice. Whenever the Notice is revised,
we must make the Notice available upon request on or after the effective
date of the revision in a manner consistent with the above instructions.
Thereafter, we must distribute the Notice to each new patient at
the time of service delivery and to any person requesting a Notice.
We must also post the revised Notice in our office as discussed
above.
©
2002 American Dental Association
All Rights Reserved
Reproduction
and use of this form by dentists and their staff is permitted. Any
other use, duplication or distribution of this form by any other
party requires the prior written approval of the American Dental
Association.
This Form is educational only, does not constitute legal advice,
and covers only federal, not state, law (August 14, 2002).
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Pamela
Anzelc DDS
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
OUR LEGAL DUTY
We
are required by applicable federal and state law to maintain the
privacy of your health information. We are also required to give
you this Notice about our privacy practices, our legal duties, and
your rights concerning your health information. We must follow the
privacy practices that are described in this Notice while it is
in effect. This Notice takes effect 04/14/2003 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.
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USES
AND DISCLOSURES OF HEALTH INFORMATION
We
use and disclose health information about you for treatment, payment,
and healthcare operations. For example:
Treatment: We may use or disclose your health information
to a physician or other healthcare provider providing treatment
to you.
Payment: We may use and disclose your health information
to obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your 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 health
information for treatment, payment or healthcare operations, you
may give us written authorization to use your 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 health information for any reason except
those described in this Notice.
To Your Family and Friends: We must disclose your health
information to you, as described in the Patient Rights section of
this Notice. We may disclose your health information to a family
member, friend or other person to the extent necessary to help with
your healthcare or with payment for your 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 personal representative or another
person responsible for your care, of your location, your general
condition, or death. If you are present, then prior to use or disclosure
of your health information, we will provide you with an opportunity
to object to such uses or disclosures. In the event of your 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 healthcare. We will also use our professional
judgment and our experience with common practice to make reasonable
inferences of your best interest in allowing a person to pick up
filled prescriptions, medical supplies, x-rays, or other similar
forms of health information.
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Marketing
Health-Related Services: We will not use your health information
for marketing communications without your written authorization.
Required by Law: We may use or disclose your health information
when we are required to do so by law.
Abuse or Neglect: We may disclose your health information
to appropriate authorities if we reasonably believe that you are
a possible victim of abuse, neglect, or domestic violence or the
possible victim of other crimes. We may disclose your health information
to the extent necessary to avert a serious threat to your 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 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 health
information to provide you with appointment reminders (such as voicemail
messages, postcards, or letters).
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PATIENT
RIGHTS
Access:
You have the right to look at or get copies of your 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 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. Contact us 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
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 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 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 satisfactory explanation how payments will be handled
under the alternative means or location you request.
Amendment: You have the right to request that we amend your
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.
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QUESTIONS
AND COMPLAINTS
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 privacy rights,
or you disagree with a decision we made about access to your health
information or in response to a request you made to amend or restrict
the use or disclosure of your 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 also may 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 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.
Please feel free to contact our HIPAA Compliance Officer c/o
Dr Pamela Anzelc
Pamela
Anzelc DDS
380 Auburn St
Portland ME 04103
Telephone: 207-878-3540 Fax: 207-878-8152
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