If you are new to our practice, we invite you to fill out our patient forms online before your visit with our dentist, Dr. LeeAnn Hatfield. If you have any questions or concerns about these forms, please call Hatfield Cosmetic & Family Dentist at 864-968-8811. We look forward to seeing you and providing you with quality dentistry in Greer, South Carolina.
Medical History for New Patient Form
Please review the financial agreement and HIPPA Policy. When you arrive for your first visit, you will be asked to sign off on them.
Our Financial Agreement
This agreement is to inform you of your financial obligation to our practice. We are committed to providing you with the highest quality dental care, using only the best materials and technology available in the market today. We are also committed to providing you with up-to-date information and education tools so that you may fully participate in maintaining optimum oral health. 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 company. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with the 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. Please understand that while the practice will file claims with your insurance company on your behalf, you will remain responsible for what is not paid by the insurance company. Furthermore, if the practice cannot verify eligibility of insurance benefits prior to treatment, we will require that you pay in full for services at the time they are rendered. Understand that if treatment or care is suspended at any time by the patient, all fees for professional services rendered will be immediately due.
Your estimated co-payment for treatment, which is the amount not covered by your insurance, is due at the time service is provided. Your co-payment may be adjusted after the time of service depending upon the final reconciliation of the insurance payments.
I,___________, understand that the practice may charge the following items:
- A fee for each appointment that is missed/cancelled without a 24-hour advance notice.
- An appointment is considered missed after 15 minutes of scheduled time.
- After 3 missed appointments, you may be subject to dismissal from the practice.
- $35.00 fee for returned checks.
- A late fee if payment on my account is not received by the due date.
I agree, to the extent permitted by law, that if my account balance is referred to any agency or attorney(s) for collection purposes, to pay reasonable attorney’s fees and any expenses or costs relating to the collection proceedings, including court costs.
HIPAA Your Privacy Rights
We strongly believe in doing everything we possibly can to safeguard the privacy and security of your health information and records. As a result, we have designed our office management procedures to make sure we can follow the Health Information Portability and Accountability Act (HIPAA). HIPAA also confers on you additional rights regarding the control and use of your health information, meaning you have more access and control. Please take a few minutes to review these rights. We’re happy to answer any questions you may have.
Control Over Your Health Information
All healthcare providers (and health plans) are now required to give you a written explanation of how they use and disclose your personal health information before they can treat you. This way, you can decide if a provider is doing everything they should to protect your privacy before you choose them as your caregiver.
We must, by law, post a Notice of Privacy Practices, which outlines how we secure the privacy of patient information, in a place where you can easily see it.
Patient Recourse If Privacy Protections Are Violated
Every healthcare provider must also inform you of grievance procedures. If your privacy is violated, report the incident to your Privacy Officer immediately. You also have the right to report any violation to the department of Health and Human Services, Office of Civil Rights, 200 Independence Ave. S.W., Washington, DC 20201.
If you decide to file a grievance either with us or with the Department of Health and Human Services, we are not allowed to discriminate or retaliate you in any way.
Aside from these rights to access and control of your medical information under HIPAA, there are also clear limits on all healthcare providers regarding how they disclose medical information. Here are some of the key aspects of these boundaries:
- Providers must ensure that health information is not used for non-health purposes.
- There are clear, strong protections against using health information for marketing.
- Use only the minimum amount of information necessary.
There are situations where healthcare providers may not have to follow these privacy rules. They include: emergency circumstances, identification of a body or the cause of death, public health needs, judicial and administrative proceedings, limited law enforcement activities, and activities related to national defense and security.
We must get your signature for non-routine uses and disclosures of your information. A non-routine use is any situation not directly related to treatment, payment or operations.
Access To Your Health Information
You can get copies of your medical records simply by asking for them. Healthcare providers are required to get you a copy of your records within 60 days of your request. There may be a cost for this service.