FINANCIAL
Financial Information and Payment Options
For your convenience, we accept all major credit cards, cash and checks (with appropriate identification). Additionally, we are pleased to offer options through our lending partners; CareCredit and LendingClub. The lending partners offer short-term, interest-free solutions as well as long term solutions with competitive rates. We understand that many times dental expenses are unplanned, and therefore we have planned these lending benefits with our patients in mind.
Please note that your insurance policy is an agreement between you and the insurance company. The insurance policy does not take the place of your responsibility for full payment. Again, financial options through our lending partners CareCredit and Lending Club will be available to provide you financial options until your balance due is paid. VIP Family & Sedation Dentistry staff will do their best to verify your insurance benefits to determine coverage. However, any such verification is not a guarantee of payment by your insurance company. Final determination of payable benefits is determined by your insurance company at the time the claim is received and processed by them.
Please remember that you are fully responsible for all fees charged by this office regardless of your insurance coverage. Your estimated financial responsibility will be based on your primary dental insurance coverage. As a courtesy, after your primary dental insurance processes, we will submit a claim to your secondary dental insurance on your behalf.
Most insurance companies will respond within four to six weeks with an explanation of benefits (“EOB”). Any remaining balance after your insurance has paid is your responsibility and you will receive a statement for the amount due. Your prompt remittance is appreciated.
In cases of divorced parents, the parent bringing the child to the appointment agrees to be the guarantor for the visit(s) and will be responsible for payment; no exceptions. Should a parent disagree with this policy, the parents will be required to determine which parent is the guarantor and that parent shall be with the child at and during the appointment(s) and sign all financial and treatment documents as the guarantor.
If you have questions regarding your account, please contact us. Many times, a simple telephone call will alleviate any misunderstandings.
PRIVACY PRACTICE
VIP Family & Sedation Dentistry, PLLC
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.
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OUR LEGAL DUTY
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 must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 5/18/18, and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.
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USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:
Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
Health Care Operations: Your health information may be used as necessary to support day to day activities and management of Oral and Dental Surgery. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.
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 to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.
To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with payment for your healthcare, but only if you agree that we may do so.
Persons Involved in Care: 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, of your location or your general condition. 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 use 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 also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-ray, or other similar forms of health information.
Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.
Required by Law: We may use or disclose your health information when we are required to do so by law.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonable believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
Appointment reminders: We may use or disclose your health information to provide you with appointment reminders (such as voice mail messages, postcards, or letters).
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PATIENT RIGHTS
You have certain rights under the federal privacy standards. These include:
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The right to request restrictions on the use and disclosures of your protected health information
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The right to receive confidential communications concerning your medical condition and treatment
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The right to inspect and copy your protected health information, a fee will be charged for the duplication of records.
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The right to amend or submit corrections to your protected health information
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The right to receive an accounting of how and to whom your protected health information has been disclosed
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The right to receive a printed copy of this notice
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If you want more information about our privacy practices or have question or concerns, please contact us.
If your are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at an alternative location, you may complain to the US Department of Health and Human Services upon request.
We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the US Department of Health and Human Services.
CONTACT PERSON
The name and address of the person you can contact for further information concerning our privacy policy practices is:
Dr. Massoud Eftekhari
830 S Main St, Suite 1D
Cottonwood, AZ. 86326