I, the undersigned patient, certify that the above is accurate and complete to the best of my knowledge. I will notify Dr. Ceino and/or the staff of any changes in the above prior to appointment

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Appointment Policy

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We reserve your appointment time specifically for you. If you need to reschedule please give us at least 48 hours notice not including weekends so that we may give someone else the opportunity to utilize that time.

A fee will be charged for late cancellations and/or missed appointment depending on the length, $30 per 30 minutes.

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Consent for Dental Treatment

 

I, the undersigned patient, hereby give consent for Dr. Ceino and staff to examine me, clean my teeth, perform all necessary dental treatment, administer local anesthetics, apply topical fluoride, take diagnostic radiographs, take clinical photographs and other records necessary for an accurate diagnosis for me.

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Financial Policy

 

This financial agreement is intended to facilitate our ability to provide excellent service to you while minimizing our administrative costs. All charges you incur are your responsibility regardless of your insurance

coverage. We must emphasize that as you r dental care provider, our relationship is with you and not with your insurance company.

Your insurance policy is a contract between you, your employer, and the insurance company. Our office is not a party to that contract. If payment from your insurance company is not received within 60 days from the date of service, you will be expected to pay the balance in full. As a courtesy to you we will help you process all your insurance claims. In order for our office to file your insurance claim, you must bring a complete dental insurance form or proof of insurance at each appointment. Your estimated copayment

for treatment which is the amount not covered by your insurance is due at the time of service is provided. Your co-payment may be adjusted after the time

of service depending upon final reconciliation of insurance payment.

Our office accepts cash, Master Card, Visa, and Discover.

Please do not hesitate to ask if you have any questions regarding this financial agreement.

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Notice of Privacy Practices:

HIPPA Disclosure of Health Information

 

We use and disclose health information about you for treatment, payment, and health operation. We may disclose your information to a health

care provider treating you via telephone, mail, or e-mail. You

may give us written authorization to disclose health information for any purpose. This authorization may be revoked in writing. We need written permission before any health information is disclosed. In the event of any emergency, we will disclose information based on our professional judgment. We may use your health information to obtain payment for services. We will not use health information for marketing purposes. If we suspect a possible victim abuse, neglect, or domestic violence, we may disclose your health information as the law requires. We may disclose your health information to provide you with an appointment reminder/confirmation or treatment recommendation (such as voicemails, postcards, e-mails, or letters).

Appointment Reminders

 

We may e-mail you or leave a message with a person or an answering machine/voicemail to reconfirm appointments. These e-mails/messages will be of non-sensitive nature and will include the doctor’s name and/or the practice name. You may inform us in writing if you prefer to not to have

e-mails/messages of this nature left for you.

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Please send appointments reminders and other information regarding this

appointments to the following e-mail:

 

 

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If you prefer via phone, please indicate the best phone number: 

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Patient Rights

Access: You have the right to look at or obtain your health information. If you request copies, we will charge you for each page, for staff time to locate and copy of information and postage if you request it to be mailed.

Restriction: You have a right to request that we place additional restrictions on our use or disclosure of information.

Alternative Communication: You have the right to request that we communicate with you about your health history in alternative means.

Amendment: You have the right to request that we amend your health information. We may deny your request under certain circumstances.

 

Questions and Complaints

If you are concerned that we may have violated your privacy rights or disagree with a decision we made about access to your health information you may submit a written complaint to the U.S. Department of Health and Human Resources.

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