Privacy & HIPAA Policy
Personal Health Information (PHI)
At Dental Faith, we know that the privacy of your personal information is important to you. The need for the strict confidentiality of personal information about our patients is taken very seriously. This document sets out our policy for maintaining confidentiality and all members of the practice team must comply with these safeguards as part of their contract of employment/contract for services with the practice. We are committed to safeguarding the privacy of your information and want you to know the protective measures we take.
Our website address is: https://dentalfaith.com.
The Dental Practice Covered By This Notice:
This Notice describes the privacy practices of Dental Faith. “We” and “our” means the Dental Practice. “You” and “your” means our patient.
Information Covered By This Notice:
This Notice applies to health information about you that we create or receive and that identifies you. This Notice tells you about the ways we may use and disclose your health information. It also describes your rights and certain obligations we have with respect to your health information. We are required by law to:
– Maintain the privacy of your health information;
– Give you this Notice of our legal duties and privacy practices with respect to that information;
– Abide by the terms of our Notice that is currently in effect.
Consent for Services, Appointment and Payment Policy
Broken or Cancelled Appointments:
If you need to cancel an appointment, please notify us at least 24 hours in advance for Tuesday through Saturday appointments and no later than 10:00 am Friday for Monday appointments. If we cannot confirm the appointment with you, it may be given to someone else.
We charge $50.00 for each canceled or broken appointment if you do not give us the required advance notice. Please notify us if an emergency makes it impossible for you to give 24 hours notice so we can discuss this with you.
Please DO NOT cancel an appointment with a voicemail message or text. Instead, we require you to please talk to us during office hours to avoid confusion. Our office hours are Monday through Friday from 10:00 am to 6:00 pm and Saturday from 9:00 am to 3:00 pm.
Appointment Arrival:
Please arrive 10 minutes prior to your appointment. If you arrive 15 minutes late or more to your appointment you will likely be asked to reschedule unless we can still accommodate you.
Office Surveillance:
Please be advised that Dental Faith is equipped with a surveillance system throughout the clinic for your safety and ours. For your privacy, the surveillance system is not shared with any external sources and falls within HIPPA regulations regarding visual recordings.
Copy and/or Transfer of your X-Rays:
You have the right to copy your X-Rays, by filling out the release authorization form, records will be sent within 2-3 business days of the receipt of your written request. For providing an electronic or paper copy of your X-Rays, we will charge you an administrative fee $25.00 in responding to your request.
Minors in the Office:
Minors must always be accompanied by an adult. The adult accompanying a minor will be responsible for payment of services on their appointment. If parent is giving authorization for a Caregiver, the permission form needs to be completed prior to their visit.
Payment is due at the time of treatment:
Payment for treatment is due in full at the time of treatment, unless you have made other payment arrangements with us. If we are filing an insurance claim for you, please read the next section for an explanation of payment arrangements.
Insurance Claims:
If we file an insurance claim for you, you will need to pay us at the time of treatment the expected estimated insurance deductible and any estimated amount that we expect insurance will not cover.
We try to get accurate information about insurance benefits and coverage before treatment, but we cannot be sure what the insurance company will pay, if anything, until the claim is submitted, and the insurance company actually pays on the claim. It is not unusual for insurance companies to give us erroneous information about coverage or benefits. This is important because you are responsible for all treatment charged, whether or not your insurance company provides any benefits
Returned Checks:
Please take every precaution to avoid giving us a bad check. It is time consuming for our staff to deal with returned checks and this takes away from the more important job of providing dental services. For this reason, we charge $30.00 for any check that is returned to us without payment. Also, if you have given us a bad check in the past, we will not accept a personal check from you in the future as payment for dental services.
Interest on late payments:
Please pay your charges on time. We rely on prompt payment from our patients and their insurance companies. We will charge your account interest at the rate of 1.5% per month (18% annually) for charges not paid within 30 days. We recommend patients understand their insurance benefits and monitor their plans for prompt payment.
Collection Costs:
We will charge your account for our collection costs if we refer your account to an outside agency or attorney for collection. These costs include the collection agency’s commission and, if an account is collected after the start of a collection lawsuit, reasonable attorneys’ fees and expenses and court costs. For a referred account that is collected prior to the start of a collection lawsuit, we will add 43% to the principal amount due so that the office will be left with the full principal amount after deducting the collection agency’s commission from the amount collected.
Our Use and Disclose of Your Health Information Without Your Written Authorization:
Common Reasons for Our Use and Disclosure of Patient Health Information Treatment. We will 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.
Healthcare 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, voicemail, or email.
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.
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.
Policy Changes and Complaints
We Have the 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 and in our office and will provide a copy of it to you on request. The effective date of this Notice (including any updates) is in the top right-hand corner of the Notice.
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. The privacy of your health information is important to us. We will not retaliate against you in any way if you choose to file a complaint.
Contact Us
Get In Touch
Dental Faith is happy to take care of your dental needs. Please help us by following our appointment and payment policies. If you have any questions or would like further information about this Notice, you can either write to or call the Privacy Official for our Dental Practice:
- Office: Dental Faith
- HIPAA Policy Official: Dr. Paula M. Fedler
- Mailing Address: 390 Harding Place, Suite 101, Nashville, TN 37211
- Email: [email protected]
- Phone: 615-285-3949
- Fax: 615-285-3950
