Patient Resources

Authorization to Release Records
It is important to understand that your medical and dental care history is often shared among medical and dental professionals as a necessary element of your care. We will provide you with a form-of-authorization to complete and sign when we seek to obtain your records, radiographs and other personal health information from another provider.
Such an authorization will often include the following:
1. Detailed description of the information to be released
2. To whom may the information be released [name(s) or class(es) of recipients]
3. The purpose(s) for the release (if the authorization is initiated by the individual, it is permissible to state “at the request of the individual” as the purpose, if desired by the individual)
4. Expiration date or event relating to the individual or purpose for the release.
It is completely your decision whether or not to sign this authorization form. We cannot refuse to treat you if you choose not to sign an authorization. If you sign an authorization, you may revoke it later. The only exception to your right to revoke is if we have already acted in reliance upon the authorization. If you want to revoke your authorization, send the office a written or electronic note telling us that your authorization is revoked. When your health information is disclosed as provided in this authorization, the recipient often has no legal duty to protect its confidentiality. In many cases, the recipient may re-disclose the information as he/she wishes. Sometimes, state or federal law changes this possibility.

Notice of Privacy Practices
We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This notice describes how we protect your health information and what rights you have regarding it.
TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
The most common reason why we use or disclose your health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you, examining your teeth, prescribing medications and faxing them to be filled, referring you to another doctor or clinic for other health care or services, or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health or dental care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). “Health care operations” are the administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records. We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside of our office for these reasons, we will ask you for special written permission.
USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION
In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us, some may never come up at our office at all. Such uses or disclosures are:
• When a state or federal law mandates that certain health information be reported for a specific purpose
• For public health purposes, such as contagious disease reporting, investigation or surveillance, and notices to and from the Federal Food and Drug Administration regarding drugs or medical devices
• Disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence
• Uses and disclosures for health oversight activities, such as for the licensing of doctors, for audits by Medicare or Medicaid, or for investigation of possible violations of health care laws
• Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies
• Disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime, to provide information about a crime at our office, or to report a crime that happened somewhere else
• Disclosure to a medical examiner to identify a dead person or to determine the cause of death, to funeral directors to aid in burial, or to organizations that handle organ or tissue donations
• Uses or disclosures for health related research
• Uses and disclosures to prevent a serious threat to health or safety
• Uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials, for lawful national intelligence activities, for military purposes, or for the evaluation and health of members of the foreign service
• Disclosures of de-identified information
• Disclosures relating to worker’s compensation programs
• Disclosures of a “limited data set” for research, public health, or health care operations
• Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures
• Disclosures to “business associates” who perform health care operations for us and who commit to respect the privacy of your health information.
Unless you object, we will also share relevant information about your care with your family or friends who are helping you with your dental care.
APPOINTMENT REMINDERS
We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call or write to notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a post card, and/or leave you a reminder message at the phone numbers you provide.
OTHER USES AND DISCLOSURES
We will not make any other uses or disclosures of your health information unless you sign a written authorization form. The content of an authorization form is determined by federal law. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if it is your idea for us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form, or you can use one of ours. If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing and sent to the office.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
The law gives you many rights regarding your health information. You can:
• Ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to the office.
• Ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using e-mail to your personal e-mail address. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to the office.
• Ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us (or 60 days if the information is stored off-site). You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to the office.
• Ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know received the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30 day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to the office.
• Get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want). By law, the list will not include: disclosures for purposes of treatment, payment or health care operations, disclosures with your authorization, incidental disclosures, disclosures required by law, and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30 day extension of time if we notify you of the extension in writing. If you want a list, send a written request to the office.
• Get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you got one electronically or in paper form already. If you want additional paper copies, send a written request to the office.
OUR NOTICE OF PRIVACY PRACTICES
By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office, have copies available in our office, and post it on our website.
COMPLAINTS
If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office. If you prefer, you can discuss your complaint in person or by phone.
FOR MORE INFORMATION
If you want more information about our privacy practices, call or visit the office.

Thank you for choosing our office for your dental care.  Our primary mission is to deliver the best and most comprehensive dental care available.  An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.

Payment Options

You can choose from:

• Cash, check, VISA, MasterCard, American Express or Discover Card
• Payment plans through Care Credit (contact our office for more information)

Please note that our office requires payment in full at the time of service for all treatment services except as described below:

• For treatment requiring more than 3 appointments, alternative payment arrangements may be provided. For these types of treatment and more comprehensive treatment plans, a deposit of one-half of the total fee is required at your initial treatment appointment.
• For patients with dental insurance (except Delta Dental and BCBS plans), we will work with your carrier to maximize your benefits and bill them directly for your treatment. Any difference between our fees and the insurance reimbursement is your responsibility.
• For patients with Delta Dental and BCBS plans, it should be noted that Crescent Dental Associates is an out-of-network provider. Therefore, the full fee for treatment is due at the time of service.  We will then submit a claim for you and the carrier will send payment directly to you in accordance with the terms of your particular insurance plan.
• For patients with Altus Dental, Crescent Dental Associates is an in-network provider and as such, abides by the Altus treatment fees as dictated by your plan and until annual maximums are reached.
• A fee of $175 may be charged for patients who miss or cancel an appointment more than two (2) times per calendar year without 24 hour notice.
• There is a charge of $25 for returned checks.

If you have questions or concerns, please contact us.  We are here to help you achieve your treatment goals.

 Crescent Dental Associates has met and often exceeds the infection control recommendations of the Center For Disease Control and the American Dental Association since guidelines were first introduced.

• All of our dental handpieces and hand instruments are put through a state of the art autoclave sterilization after EVERY PATIENT USE.
• We use as many disposable items as possible. All of these items are discarded after every patient. Masks, towels, cups and similar items are never used more than once.
• Equipment handles are also protected with disposable plastic covers.
• Staff always practices proper hand washing techniques.
• The staff’s practice of using gloves and changing them before every patient is never violated.
• Before and after each patient, all work surfaces, chairs, lights and units are disinfected with a strong anti-bacterial agent.
• Training of our staff is an ongoing process with in-office review of sterilization procedures as well as continuing education courses to learn the latest techniques.

To help our patients find answers to questions they may have regarding their oral health, the American Dental Association has developed a Web site that we believe provides a perfect solution for doing this.

To access this information, please click onto the following link: MouthHealthy.org