THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, to be kept confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPAA” provides penalties for covered entities that misuse personal health information.
As required by “HIPAA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how use may use and disclose your health information. We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operations.
Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include referrals to orthodontists or oral surgeons. Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment. Health Care Operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review. We may also create and distribute de-identified health information by removing all references to individually identifiable information.
We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.
You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:
The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it. The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations. The right to inspect and copy your protected health information. Please note that there is a cost-based fee for this service. The right to amend your protected health information. The right to receive an accounting of disclosures of protected health information. The right to obtain a paper copy of this notice from us upon request. We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.
This notice is effective as of April 14, 2003 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.
You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.
At Park West Dentistry, we strive to inform you of any limitations or special stipulations of your policy as a courtesy. We are always happy to call your insurance company and obtain any information they are willing to share. However, your insurance company has no obligation to give us any information and all information that is given is only an estimate. Patients who carry dental insurance should understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient's insurance forms and file your claim. However, Park West Dentistry does not render services on the assumption that our charges will be paid by an insurance company. Any balance is the responsibility of the patient. If you should ever have any questions regarding your dental insurance or our financial guidelines, please do not hesitate to ask for our help. We will always assist you in any way possible. Our office can be reached at 375-0395.
Each dental insurance policy varies which sometimes makes understanding your policy a challenge. Some employers offer several different policies which may carry different levels of coverage. Park West Dentistry hopes this brochure will help you better understand some commonly used terms.
Coverage Year: Standard coverage years are calendar or fiscal. Some insurance companies set the coverage year fiscally, for example April 1, 2005 to March 31, 2006.
Maximums: Yearly maximum amounts may vary from $500 to over $2,000. Effective Date: This is the date coverage goes into effect. Knowing the effective date of coverage is important because it coincides with any waiting periods on treatment.
Waiting periods: Knowing the waiting period for certain procedures is important so you can determine out-of-pocket expenses. For example, if you need a crown, but there is a 12 month waiting period for major dentistry, your out-of-pocket expenses would be 100% instead of the standard estimated 50% if services are performed before the 12 month waiting period is satisfied.
Frequency Limitations: It is helpful to know frequency limitations for certain procedures. The standard frequency limitations written on most contracts are preventive which include cleanings, exams and radiographs. Cleanings and exams are commonly covered twice a year or every six months. The two are different and it is important to know which one applies to you. If the coverage is every 6 months, you have to wait six months to the day to have your second cleaning of the year or it will not be covered.
Replacement-of-Major Dentistry Frequency: This applies to major dental work such as crowns. The standard frequency limitation on replacement is typically once every five years. A new trend that we are seeing is replacement covered once every seven or ten years.
Periodontal Frequency Limitations: Scaling and Root Planing may have a frequency limit of two to five years. Additionally, the periodontal cleanings that are recommended following this procedure could be limited to once every 24 months.
Percentage and Fee Scheduled Policies: There are two types of dental plans: one designed to pay a percentage of an allowable fee and one designed to pay according to a fee schedule. The fee schedule plan pays a certain amount per procedure no matter what is charged by a dentist. The percentage of coverage plan is divided into categories: Preventive, restorative and major. Each category usually has a different percentage of coverage which varies depending on your dental plan. It is important to understand which one of these plans applies to you.
Non-Duplication Clauses: The standard definition of a non-duplication clause is that if a patient is covered under two plans and the primary plan pays 80% of the claim, the secondary plan will not duplicate the benefit. This makes it impossible to estimate your co-payment for procedures because this is only determined after a true claim is filed. We will try to obtain all benefits that are allowed from both of your policies.
Cash, Checks and Credit Cards We accept cash, checks, debit cards and all major credit cards (MasterCard, Visa, American Express, and Discover).
Financing Options We have partnered with Wells Fargo and CareCredit, two leading Healthcare Finance Companies; in order to offer patients payment plan options should you choose to finance treatment here at Park West Dentistry. We have short and long term choices available. Below you will find program highlights for your consideration. Should you decide to proceed with financing, instructions for moving forward are below. In order to take advantage of the following options, a credit authorization/application is necessary. Please let us know if you have any questions.
No Interest Payment Plans (Available from Wells Fargo)
Each month you are required to pay the required minimum monthly payment to avoid interest. The
promotional purchase must be paid in full within the promotional period to avoid interest charges. If
the payment plan is not adhered to properly, interest will be charged and APR could exceed 20%.
- 6 Months with Regular, Equal or No Payments
Extended Payment Plans (Available from Wells Fargo)
- No Set Term Limit
- 9.9% Interest
- Regular Payments
Should you decide to proceed with a Wells Fargo Finance Program, please complete the blue credit application entitled "Apply Today" provided by our office. If you would like an application mailed to you, please call (375-0395) or email (frontdesk@amandaseay.net) to request one. Please then return the form to us and we will submit it to Wells Fargo for a credit approval.
Extended Payment Plans (Available from CareCredit)
Minimum Treatment Amount is $1,000
- 12 Months - No Interest
- 24, 36, 48 and 60 Month Options Available - 11.90%
Should you decide to proceed with a CareCredit Program and you have internet access, please go to http://www.carecredit.com, click on "Apply Now" and type in our phone number as 8433750395 under "Search for my doctor". Then follow the prompts and your approval and credit limit will be provided instantaneously. If you would prefer to complete a paper application, please call (375-0395) or email (frontdesk@amandaseay.net) to request one. Please then return the form to us and we will submit it to CareCredit for an approval.
Calculators: If you would like to use a payment calculator to help determine which program is best for you, one may be found at www.carecredit.com on the home page. Another simple loan calculator may also be found at http://www.planningtips.com/cgi-bin/simple.pl
Today, under local anesthesia, we have thoroughly removed tartar and infected tissue from the roots of your teeth. Areas of more advanced periodontal disease may require repeated treatment to maximize healing potential. Our goal is to help you achieve a maintainable state of oral health.
Your own oral hygiene determines your healing response. Resume brushing at the gumline and using any prescribed rinses today and begin flossing tomorrow. Tenderness when brushing or flossing may last several days. Thorough plaque removal must be accomplished and will help reduce tenderness and sensitivity, as well as maximize healing.
Maintaining a balanced diet is essential for proper healing. Your next meal should be nourishing yet soft. Avoid crunchy foods such as popcorn, nuts, and chips, as well as foods with small seeds. These foods can become lodged under your gums and delay healing. You may return to your normal diet as soon as tenderness subsides.
Please do not smoke following your procedure. Tobacco smoke and the heat it produces retards healing. Refrain from smoking for 24 hours or longer.
We do not expect you to have any difficulty following your visit today, yet please be aware of these potential side effects:
Numbness will persist for two to four hours depending on the type of local anesthetic and area of application. Please try not to bite your cheeks, lips or tongue as they will be very sore once the numbness subsides.
Slight bleeding is normal for up to 48 hours following your visit. A moist tea bag may be applied with direct pressure for fifteen minutes to stop excessive bleeding. Please contact our office if bleeding persists beyond a few hours.
Gum discomfort can be expected. Two Advil or Tylenol taken every 6 to 8 hours as needed should relieve discomfort. Warm salt-water rinses (1 tsp salt/8 oz water) every 3 to 4 hours the first few days after your procedure will aid in healing irritated areas. If pain is persistent or excessive, please contact our office.
Tooth sensitivity following this procedure may occur. This can result from exposure to hot or cold foods, beverages, or air as well as to sweet, salty, spicy, or acidic foods. Brushing and flossing may cause sensitivity also. For most people, this resolves within a few weeks. If necessary, a sensitivity gel can be dispensed.
Please contact our office at 375-0395 if you experience any of the following: persistent and/or excessive swelling or bleeding, jaw stiffness, pus drainage, or bad taste.
HOME CARE INSTRUCTIONS FOR YOUR CROWN OR BRIDGE TEMPORARY
Your tooth has been prepared for a fixed crown or several teeth have been prepared for a bridge. Your temporary is cemented with “temporary” cement so it will come off easily when we place your permanent crown or bridge.
We will make every effort to have your crown or bridge back from the lab within 2-3 weeks. Your temporary must remain in place to prevent any possible movement of this prepared tooth. This will ensure that the permanent crown or bridge will fit properly. It is important that the temporary crown be left on only for a minimal amount of time (3-4 weeks) in order to maintain tissue health and avoid tooth movement. Please make sure to keep your “seat” appointment to avoid having to have the procedure redone at possible additional expense.
Your tooth may experience some sensitivity to hot and cold as well as to pressure. Try to avoid extremes of hot and cold foods. Totally avoid sticky or hard foods like gum, ice, or tough meats that could pull off your temporary. Brush carefully and floss or irrigate as instructed.
In the even your temporary should come off:
SAVE IT! Should we not be in the office, place some Vaseline into the crown and try to position it correctly on the tooth (until your bite feels good).
Call the office when the temporary comes off so that we may recement it. The sooner it is recemented, the less chance there is of tooth movement.
Do not leave your temporary crown or bridge off your tooth for more than 3 days. This could cause your permanent crown or bridge not to fit properly due to excessive movement of the prepared tooth or adjacent teeth. In such a case, the whole procedure would have to be redone at possible additional expense.
If you have any questions regarding your temporary, please call the office anytime at (843) 375-0395.
3404 Salterbeck Street, Suite 202 Mount Pleasant, South Carolina 29465
P. 843.375.0395 F. 843.375.0398 www.amandaseay.net
HOME CARE INSTRUCTIONS FOR YOUR ONLAY OR INLAY TEMPORARY
Your tooth has been prepared for an onlay or inlay. Your temporary or provisional onlay is cemented with “temporary” cement so it will come off easily when we place your restoration.
We will make every effort to have your onlay back from the lab within 2-3 weeks. Your provisional onlay must remain in place to prevent any possible movement of this prepared tooth. This will ensure that the permanent onlay will fit properly. It is important that the provisional onlay be left on only for a minimal amount of time (3-4 weeks) in order to maintain tissue health and avoid tooth movement. Please make sure to keep your “seat” appointment to avoid having to have the procedure redone at possible additional expense.
Your tooth may experience some sensitivity to hot and cold as well as to pressure. Try to avoid extremes of hot and cold foods. Totally avoid sticky or hard foods like gum, ice, or tough meats that could pull off your provisional restoration. Brush carefully and floss or irrigate as instructed.
In the even your provisional onlay should come off:
SAVE IT! We may be able to recement this provisional restoration and avoid making a new one.
Call the office so that we may recement it. The sooner it is recemented, the less chance there is of tooth movement.
Your provisional onlay should not be left out of your tooth for more than 3-4 days. This could cause your permanent onlay not to fit properly due to excessive movement of the prepared tooth or adjacent teeth. In such a case, the whole procedure would have to be redone at possible additional expense.
If you have any questions regarding your provisional restoration, please call the office anytime at (843) 375-0395.
3404 Salterbeck Street, Suite 202 Mount Pleasant, South Carolina 29465
P. 843.375.0395 F. 843.375.0398 www.amandaseay.net