Medical Form Terms and Conditions General
I understand that the information that I have provided today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence, and it is my responsibility to inform this office of any changes in my medical status.
I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
This office reserves the right to verify the credit status of potential patients and or the legal guardians of patients prior to extending credit for treatment fee and may, at the discretion of the office, use the services of one or more credit reporting services.
If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any copayment and deductibles that my insurance does not cover.
Text and Email Policy
Dot Smiles Orthodontics affiliated offices can email and/or text you appointment reminders and general information about our services. By signing below, you consent to receive appointment reminders andother communications/information via email or text from our practice sent to any email address or phone number you provide to us. To opt-out at any moment, reply ‘STOP’. Any email or text messages we send may not be encrypted or otherwise protected and could be intercepted by a third party. By executing this consent, you assume the risk that the information contained in any such communication will be intercepted. We will not charge you for sending texts or emails, but charges from your carrier may apply.
I understand that this request to receive emails and/or text messages will apply to all future appointment reminders and communications sent by our practice until I request a change in writing.
Appointment Policy
POLICY FOR CANCELLATIONS: NOTIFY US NO LATER THAN 24 hrs. ONE BUSINESS DAY PRIOR TO YOUR RESERVATION TO AVOID BEING ASSESSED A $55 LATE CANCELLATION FEE.
At Dot Smiles, our goal is to offer every patient exceptional care and service. We view booked
reservations as an opportunity to deliver care to our patients in a timely manner.
Your treatment plan is provided as a series of reservations over a pre-planned time frame. It is important that you show up to each appointment to achieve optimal results. As a result, we have implemented a few guidelines to follow whenever it is necessary to reschedule an appointment:
- If you are unable to make a scheduled appointment due to an emergency, please call us at 617-
533-8058. We can help you reschedule. - For cancellations, please give us 24 hrs. notice, at least 1 business day, prior to your or your
child’s scheduled appointment. - We charge $55 PER MISSED OR CANCELLED APPOINTMENTS without a minimum of 1-
BUSINESS DAY advance notice Monday to Friday (weekend notifications are not accepted since
our office is closed). - OUR $55 MISSED OR LATE CANCEL FEE MUST BE PAID IN FULL PRIOR TO RESERVING
ANOTHER APPOINTMENT (for any and all family members). - Presenting more than 15 minutes late for a confirmed appointment may be considered a “missed
appointment”. - No walk-ins allowed.
- New Patients with 2 or more MISSED OR CANCELLED TREATMENT APPOINTMENTS will not
be able to make future reservations. If you are a patient that is currently in treatment and miss 2 or
more appointments, you risk having treatment terminated for poor compliance and excessively
missed appointments. - Any appointment that remains UNCONFIRMED via phone call/email/text 24 hrs. prior to the
scheduled appointment may be subject to AUTOMATIC CANCELLATION BY Dot Smiles.
POLICIES FOR PATIENTS OF Dot Smiles
Orthodontic treatment is a team effort requiring close cooperation between the patient, doctor and
parents of minor patients. We request your cooperation with us in the following areas:
Check-In/Patient Updates: Adult patients and parents of minor patients receiving treatment are
requested to check-in at the front desk for all appointments. Any changes in a patient’s medical history must be reported to either, staff at the front desk, the Orthodontist or an orthodontic assistant.
Parents and Visitors: Once active orthodontic treatment has begun on patients, we request that unless you are the patient being treated or unless the Orthodontist asks you to remain in the treatment area, you please wait in the reception area at the front of the office.
Hygiene: Great hygiene results in healthy teeth and gums. Patients should follow the directions provided
concerning proper brushing and hygiene techniques. Poor oral hygiene can lead to decalcification and white spots on the teeth. We cannot assume responsibility for the occurrence of such problems due to poor hygiene.
School Hours Appointments: Must be made for certain orthodontic procedures due to their length and nature. In order to accommodate more patients with after school time, we only allow shorter appointments after 2:30pm.
Diet: Patients are instructed to avoid foods that are SWEET, STICKY and HARD. Patients are requested
to avoid excessive intake of sweet foods with refined carbohydrates. Too many sweets will lead to decay and white spots on the teeth. We cannot assume responsibility for such problems due to poor diet.
Broken Appliances: Fortunately, most patients experience minimal breakage. We request that patients follow our instructions concerning diet and care for appliances. Extensive breakage can prolong treatment and affect the quality of care. If a bracket or band breaks or becomes loose, please notify our office.
There will be a charge of $55.00 for each broken bracket or band after three occurrences or three or
more brackets at an appointment.
Length of treatment: Treatment time varies from patient to patient. We try to estimate as accurately as we can the length of treatment for our patients. There are variables that will affect the time of treatment such as growth, cooperation, etc. Exact treatment time is impossible to predict and estimate. It is within the Orthodontist’s complete discretion to determine when treatment has been completed.
Respectful Relationship: Patients, parents or any visitor to this office will be treated in a professional,
polite, and respectful manner. The same behavior is expected of patients and patrons of this office.
Insurance Coverage: It is the parent and/or patient’s responsibility to ensure that the patient remains eligible and covered for orthodontic services by their insurance carrier during the course of treatment. If a patient loses their orthodontic benefit during treatment, or the insurance carrier does not pay for the treatment, the balance remaining on the account will be the responsibility of the patient/parent/guardian.
We hope your experience at our office is positive and rewarding. If we can be of any assistance to you, please do not hesitate to ask.
The Orthodontist reserves the right to withdraw and stop treatment of patients who are not compliant with the policies outlined in this document. I have reviewed the Policies for Patients of Dot Smiles and agree to the terms.
Benefits of Orthodontics
Orthodontics provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment.
I consent to have an orthodontic examination and authorize the performance of diagnostic procedures
and treatments that may be necessary for proper orthodontic care. I have truthfully answered all the
above questions and agree to inform this office of any changes in my medical or dental history. I
AUTHORIZE THE RELEASE OF ANY INFORMATION RELATING TO THE INSURANCE CLAIM AND
UNDERSTAND THAT I AM RESPONSIBLE FOR ALL COSTS OF DENTAL TREATMENT. I HEREBY
AUTHORIZE PAYMENT DIRECTLY TO Dot Smiles OF THE GROUP INSURANCE BENEFITS
OTHERWISE PAYABLE TO ME FOR ANY ORTHODONTIC RELATED CARE PROVIDED BY Dot
Smiles. I have read and understand this document in its entirety.
Non-Discrimination Policy
DISCRIMINATION IS AGAINST THE LAW. Dot Smiles Orthodontics complies with applicable Federal civil
rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
Dot Smiles Orthodontics does not exclude people or treat them differently because of race, color,
national origin, age, disability, or sex. Dot Smiles Orthodontics provides free aids and services to people with disabilities to communicate effectively with us, such as: qualified sign language interpreters, and
written information in other formats (large print, audio, accessible electronic formats, other formats). Dot Smiles Orthodontics provides free language services to people whose primary language is not English, such as: qualified interpreters, and information written in other languages.
Notice of Privacy Practices
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.
I. Dental Practice Covered by this Notice
This Notice describes the privacy practices of Dot Smiles (“Dental Practice”). “We” and “our” means the Dental Practice. “You” and “your” means our patient.
II. How to Contact Us/Our Privacy Official
If you have any questions or would like further information about this Notice, you can contact dotSmile’s Privacy Official at:
Melissa Sullivan
126 Granite Ave
Dorchester, MA 02124
info@Dot Smiles.com
or 617-533-8058
III. Our Promise to You and Our Legal Obligations
The privacy of your health information is important to us. We understand that your health information is
personal and we are committed to protecting it. This Notice describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other
purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected health information is information about you, including
demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
We are required by law to:
Maintain the privacy of your protected health information; Give you this Notice of our legal duties and privacy practices with respect to that information; and Abide by the terms of our Notice that is currently in effect.
IV. Last Revision Date
This Notice was last revised on October 1st 2013.
V. How We May Use or Disclose Your Health Information
The following examples describe different ways we may use or disclose your health information. These
examples are not meant to be exhaustive. We are permitted by law to use and disclose your health
information for the following purposes:
A. Common Uses and Disclosures
- Treatment. We may use your health information to provide you with dental treatment or
services, such as cleaning or examining your teeth or performing dental procedures. We may
disclose health information about you to dental specialists, physicians, or other health care
professionals involved in your care. - Payment. We may use and disclose your health information to obtain payment from health
plans and insurers for the care that we provide to you. - Health Care Operations. We may use and disclose health information about you in connection
with health care operations necessary to run our practice, including review of our treatment and
services, training, evaluating the performance of our staff and health care professionals, quality
assurance, financial or billing audits, legal matters, and business planning and development. - Appointment Reminders. We may use or disclose your health information when contacting
you to remind you of a dental appointment. We may contact you by using a postcard, letter, phone
call, voice message, text or email. - Treatment Alternatives and Health-Related Benefits and Services. We may use and
disclose your health information to tell you about treatment options or alternatives or health-related
benefits and services that may be of interest to you. - Disclosure to Family Members and Friends. We may disclose your health information to a
family member or friend who is involved with your care or payment for your care if you do not
object or, if you are not present, we believe it is in your best interest to do so. - Disclosure to Business Associates. We may disclose your protected health information to our
third- party service providers (called, “business associates”) that perform functions on our behalf or
provide us with services if the information is necessary for such functions or services. For
example, we may use a business associate to assist us in maintaining our practice management
software. All of our business associates are obligated, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
B. Less Common Uses and Disclosures - Disclosures Required by Law. We may use or disclose patient health information to the extent
we are required by law to do so. For example, we are required to disclose patient health
information to the U.S. Department of Health and Human Services so that it can investigate
complaints or determine our compliance with HIPAA. - Public Health Activities. We may disclose patient health information for public health activities
and purposes, which include: preventing or controlling disease, injury or disability; reporting births or deaths; reporting child abuse or neglect; reporting adverse reactions to medications or foods; reporting product defects; enabling product recalls; and notifying a person who may have been
exposed to a disease or may be at risk for contracting or spreading a disease or condition. - Victims of Abuse, Neglect or Domestic Violence. We may disclose health information to the
appropriate government authority about a patient whom we believe is a victim of abuse, neglect or
domestic violence. - Health Oversight Activities. We may disclose patient health information to a health oversight
agency for activities necessary for the government to provide appropriate oversight of the health
care system, certain government benefit programs, and compliance with certain civil rights laws. - Lawsuits and Legal Actions. We may disclose patient health information in response to (i) a
court or administrative order or (ii) a subpoena, discovery request, or other lawful process that is
not ordered by a court if efforts have been made to notify the patient or to obtain an order
protecting the information requested. - Law Enforcement Purposes. We may disclose your health information to a law enforcement
official for a law enforcement purposes, such as to identify or locate a suspect, material witness or
missing person or to alert law enforcement of a crime. - Research Purposes. We may use or disclose your information for research purposes pursuant
to patient authorization waiver approval by an Institutional Review Board or Privacy Board. - Serious Threat to Health or Safety. We may use or disclose your health information if we
believe it is necessary to do so to prevent or lessen a serious threat to anyone’s health or safety. - Specialized Government Functions. We may disclose your health information to the military
(domestic or foreign) about its members or veterans, for national security and protective services for the President or other heads of state, to the government for security clearance reviews, and to a jail or prison about its inmates. - Workers’ Compensation. We may disclose your health information to comply with workers’
compensation laws or similar programs that provide benefits for work-related injuries or illness.
VI. Your Written Authorization for Any Other Use or Disclosure of Your Health Information
Uses and disclosures of your protected health information that involve the release of psychotherapy notes
(if any), marketing, sale of your protected health information, or other uses or disclosures not described in this notice will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke this authorization at any time, in writing, except to the extent that this office has taken an action in reliance on the use of disclosure indicated in the authorization. If a use or disclosure of protected health information described above in this notice is prohibited or materially limited by other laws that apply to use, we intend to meet the requirements of the more stringent law.
VII. Your Rights with Respect to Your Health Information
You have the following rights with respect to certain health information that we have about you
(information in a Designated Record Set as defined by HIPAA). To exercise any of these rights, you must
submit a written request to our Privacy Official listed on the first page of this Notice.
A. Right to Access and Review
You may request to access and review a copy of your health information. We may deny your
request under certain circumstances. You will receive written notice of a denial and can appeal it.
We will provide a copy of your health information in a format you request if it is readily producible.
If not readily producible, we will provide it in a hard copy format or other format that is mutually
agreeable. If your health information is included in an Electronic Health Record, you have the right
to obtain a copy of it in an electronic format and to direct us to send it to the person or entity you
designate in an electronic format. We may charge a reasonable fee to cover our cost to provide
you with copies of your health information.
B. Right to Amend
If you believe that your health information is incorrect or incomplete, you may request that we
amend it. We may deny your request under certain circumstances. You will receive written notice
of a denial and can file a statement of disagreement that will be included with your health
information that you believe is incorrect or incomplete.
C. Right to Restrict Use and Disclosure
You may request that we restrict uses of your health information to carry out treatment, payment,
or health care operations or to your family member or friend involved in your care or the payment
for your care. We may not (and are not required to) agree to your requested restrictions, with one
exception: If you pay out of your pocket in full for a service you receive from us and you request
that we not submit the claim for this service to your health insurer or health plan for
reimbursement, we must honor that request.
D. Right to Confidential Communications, Alternative Means and Locations
You may request to receive communications of health information by alternative means or at an
alternative location. We will accommodate a request if it is reasonable and you indicate that
communication by regular means could endanger you. When you submit a written request to the
Privacy Official listed on the first page of this Notice, you need to provide an alternative method of contact or alternative address and indicate how payment for services will be handled.
E. Right to an Accounting of Disclosures
You have a right to receive an accounting of disclosures of your health information for the six (6)
years prior to the date that the accounting is requested except for disclosures to carry out
treatment, payment, health care operations (and certain other exceptions as provided by HIPAA).
The first accounting we provide in any 12-month period will be without charge to you. We may
charge a reasonable fee to cover the cost for each subsequent request for an accounting within
the same 12-month period. We will notify you in advance of this fee and you may choose to modify
or withdraw your request at that time.
F. Right to a Paper Copy of this Notice
You have the right to a paper copy of this Notice. You may ask us to give you a paper copy of the
Notice at any time (even if you have agreed to receive the Notice electronically). To obtain a paper
copy, ask the Privacy Official.
G. Right to Receive Notification of a Security Breach
We are required by law to notify you if the privacy or security of your health information has been
breached. The notification will occur by first class mail within sixty (60) days of the event. A breach
occurs when there has been an unauthorized use or disclosure under HIPAA that compromises the
privacy or security of your health information.
The breach notification will contain the following information: (1) a brief description of what
happened, including the date of the breach and the date of the discovery of the breach; (2) the
steps you should take to protect yourself from potential harm resulting from the breach; and (3) a
brief description of what we are doing to investigate the breach, mitigate losses, and to protect
against further breaches.
VIII. Special Protections for HIV, Alcohol and Substance Abuse, Mental Health and Genetic Information
Certain federal and state laws may require special privacy protections that restrict the use and disclosure
of certain health information, including HIV-related information, alcohol and substance abuse information,
mental health information, and genetic information. For example, a health plan is not permitted to use or disclose genetic information for underwriting purposes. Some parts of this HIPAA Notice of Privacy Practices may not apply to these types of information. If your treatment involves this information, you may contact our office for more information about these protections.
IX. Our Right to Change Our Privacy Practices and This Notice
We reserve the right to change the terms of this Notice at any time. Any change will apply to the health information we have about you or create or receive in the future. We will promptly revise the Notice when there is a material change to the uses or disclosures, individual’s rights, our legal duties, or other privacy practices discussed in this Notice. We will post the revised Notice on our website (if applicable) and in our office and will provide a copy of it to you on request. The effective date of this Notice is June 5, 2017.
X. How to Make Privacy Complaints
If you have any complaints about your privacy rights or how your health information has been used or
disclosed, you may file a complaint with us by contacting our Privacy Official listed on the first page of this Notice. You may also file a written complaint with the Secretary of the U.S. Department of Health and
Human Services, Office for Civil Rights. We will not retaliate against you in any way if you choose to file a complaint.
Acknowledgment of Privacy Practices
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly or indirectly, obtain payment from third-party payers, and conduct normal healthcare operations such as quality assessments and physician certifications.
I acknowledge that I have received your Notice of Privacy Practices containing a more complete
description of the uses and disclosures of my health information. I understand that this organization has
the right to change its Notice of Privacy Practices from time to time and that I may contact this
organization at any time at the address below to obtain a copy of the Notice of Privacy Practices. I
understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand, you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
Acknowledgment
By signing below, I agree that I have read and understand Dot Smiles HIPAA Privacy Policy, Receipt of Notice of Privacy, Financial Policy, and Appointment Cancellation Policy forms and I agree to be bound by its terms. I also understand and agree that such terms may be amended from time-to-time by the practice. PATIENT‘S AUTHORIZED REPRESENTATIVE. If you are consenting to the care of another: I have legal authority to sign this {Signature}