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 reserve the right to change our privacy practices and the terms of this notice at any time, provided applicable law permits such changes.
We use and/or disclose health information about you for treatment, payment and healthcare operations. For example, we may disclose your health information to a physician or other healthcare provider providing treatment to you. We may use and disclose your health information to obtain payment for services we provide to you.
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 disclose it to anyone for any purpose. If you give us an authorization, you make revoke in writing at any time. Unless you give us written authorization, we cannot use or disclose your health information for any reason except those described in this notice.
Family/Friends: 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, only if you agree that we may do so.
Please list family/friend you wish to authorize at this time here:
Name: Relation:
Healthcare Providers: 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, or 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 not use your health information for marketing communications without your written consent.
We may use or disclose your health information when we are required to do so by law.
As a standard of care at our practice, we take a 3D image on each tooth/area referred. This image is a CBCT (cone-beam computed tomography) or 3D Scan.
A CBCT scan is a specialized type of x-ray that provides more information than a conventional x-ray. Our doctors rely on this scan to look for hidden/missed canals, fractures, to assist in complex root canal diagnosis, treatment planning, and reference during treatment.
Often, insurance companies will not cover CBCT images. However, their fees for these images range from $190 - $410. We charge a flat fee of $145. This fee is included in the quote given at scheduling. As a courtesy, we will file this fee to your insurance.
Please note, based on their fee/your coverage, your explanation of benefits may reflect your responsibility to be higher. We will honor our fee if your responsibility is higher than $145 or if your insurance does not pay for this service. In addition, if your insurance does not place this fee under your responsibility due to it not being a covered service under your plan, you are still responsible for this fee.
By signing below, you acknowledge you have read this non-covered service form in its entirety.