Patients with dental insurance:  We will estimate the portion your insurance is going to pay. Your insurance policy represents a contract between you and your insurance company. Patient portions (co-pay) of dental treatments are due at the time of service. We do offer several methods of payment, and if desired we will assist you with the option of third-party financing through Care Credit. Your insurance carrier does not issue guarantees of coverage and it is your insurance company that makes the final determination of benefits. Therefore, we cannot guarantee any patient portion amounts. As a courtesy to you, we will bill your insurance, but you are ultimately responsible for all charges incurred in our office. We will bill you for any remaining balances due to insurance delays (longer than 90 days), denial of claims or for any remaining balances due after your insurance pays.

·If your insurance pays more than the estimated amount, a refund check from this office will be mailed to the address we have on file.

·If your insurance pays less than the estimated amount, you will receive a statement from this office. We will send a statement every 2 weeks via USPS and to the e-mail address on file. We will make every attempt to collect any remaining balance before sending the account to collections.

Patients without dental insurance: Payment is due at time of treatment.

Payments for services provided in our office are non-refundable.

NOTE: We will make every effort to collect from your insurance company. If your insurance company does not reimburse us after 3 submissions, you will be responsible for the remainder of the balance since we were unable to collect from them.

*By signing this financial policy agreement, you acknowldege the validity of any payment(s) made in our office and agree not to file any dispute(s) with your financial institution(s). Any claim(s) filed with your financial institution(s) will automatically be turned over to a collection agency.

I have been made aware of my condition requiring endodontic (root canal) therapy in the opinion of my dentist. I am aware that the practice of dentistry is not an exact science, and no guarantees have been made to me concerning the results of the procedure. I understand that the goal of root canal treatment is to save a tooth that might otherwise require extraction. Although root canal treatment has a very high success rate, as with all medical and dental procedures, it is a procedure whose results cannot be guaranteed.

I understand that an alternative treatment might be (but not limited to):

·Extraction of the involved tooth or teeth. To be replaced with either nothing, a denture, a bridge, or an implant.

·Waiting for more definitive development of symptoms.

·Getting a second opinion by another endodontist.

·No treatment at all.

I understand that the consequences of doing nothing can lead to worsening of the condition, further infection, cystic formation, swelling, pain, loss of tooth, and/or other systemic disease and infection problems.

Although unlikely, some complications of root canal therapy may be, but are not limited to:

·Failure of the procedure necessitating re-treatment, root surgery (apicoectomy), or extraction.

·Post-operative pain, swelling, bruising, and/or restricted jaw opening that may persist for several days or longer.

·Breakage of an instrument inside the canal during treatment, which may be left as is, or may require surgery for removal.

·Perforation of the canal with instruments, which may require additional surgical treatment or result in the loss of the tooth.

·Reactions to anesthetics, chemicals, or medications.

·Changes in bite of jaw joint difficulty (TMJ problems or TMD)

·Blocked canals that cannot be ideally completed.

·Temporary or permanent numbness

·Incomplete healing.

·If the tooth already has a crown, the crown might break and a new crown might be needed following treatment.

Successful completion of the root canal procedure does not prevent future decay or fracture. An endodontically treated tooth will become more brittle and may discolor. In most cases a full crown is recommended after treatment to lessen the chance of fracture. If a crown is needed, I agree to get a crown on the treated tooth in a timely manner (generally within 30 days). I understand that failure to have the treated tooth/teeth properly restored following treatment significantly increases the possibility of failure of the root canal procedure or tooth fracture.

I understand that Four Peaks Endodontics is a non-narcotic practice and that any prescriptions given are appropriate for my care.

By providing my signature, I certify that I understand the recommended treatment, the risks of such treatment, any alternatives and the risks of these alternatives including the consequences of doing nothing. I have had a chance to have all of my questions answered and consent to the procedure.

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

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 10/12/2023, 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.

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.

Healthcare Operations:  We may use and disclose your health information in connection with our healthcare operations.  Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

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 or 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 your healthcare or 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, your general condition, or death.  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 uses 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-rays, 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 reasonably 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.

National Security:  We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances.  We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities.  We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders:  We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

Audio and Video Recordings:  We may use audio and video recordings in addition to our clinical notes in an effort to maintain the most accurate patient records possible. These recordings may also be shared with your care team on an as needed basis to aid in the most accurate communication between care professionals.

PATIENT RIGHTS

Access:  You have the right to look at or get copies of your health information, with limited exceptions.  You may request that we provide copies in a format other than photocopies.  We will use the format you request unless we cannot practicably do so.  (You must make a request in writing to obtain access to your health information.  You may obtain a form to request access by using the contact information listed at the end of this Notice.  We will charge you a reasonable cost-based fee for expenses such as copies and staff time.  You may also request access by sending us a letter to the address at the end of this Notice.  If you request copies, we will charge you $0.___ for each page, $___ per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you.  If you request an alternative format, we will charge a cost-based fee for providing your health information in that format.  If you prefer, we will prepare a summary or an explanation of your health information for a fee.  Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)

Disclosure Accounting:  You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003.  If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. 

Restriction:  You have the right to request that we place additional restrictions on our use or disclosure of your health information.  We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). 

Alternative Communication:  You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. {You must make your request in writing.}  Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment:  You have the right to request that we amend your health information.  (Your request must be in writing, and it must explain why the information should be amended.)  We may deny your request under certain circumstances.

Electronic Notice:  If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form. 

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us.

If you 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 alternative locations, you may complain to us using the contact information listed at the end of this Notice.  You also may submit a written complaint to the U.S. Department of Health and Human Services.  We will provide you with the address to file your complaint with the U.S. 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 U.S. Department of Health and Human Services.

Taking Halcion prior to your dental appointment is an excellent way to minimize or eliminate anxiety that may be associated with going to the dentist. Even though it is safe, effective, and wears off rapidly after the dental visit, you should be aware of some important precautions and considerations.

1. This consent form, the dental treatment consent forms, and treatment plan should be signed before you take the medication.

2.The onset of Halcion is 15-30 minutes. Do not drive after you have taken the medication. The peak effect occurs between 1-2 hours. After that, it starts wearing off and most people feel “back to normal” after 6-8 hours. For safety reasons and because people react differently, you should not drive or operate machinery the remainder of the day.

3.This medication should not be used if:

a)You are hypersensitive to benzodiazepines (Valium, Ativan, Versa, etc.)

b)You are pregnant of breast feeding.

c)You have liver or kidney disease.

d)You are taking the medicines nefazodone antidepressant (Serzone); cimetidine (Tagamet, Tagamet HB, Novocimetine, or Peptol); for Parkinson's disease. The following substances may prolong the effects of Halcion: Benadryl, Phenergan, Calan (Verapamil). Cardizem (diltiazem), Erythromycin, HIV drugs indinavir and nelfinavir, and alcohol. There may be unusual and dangerous reactions if you are currently taking illegal drugs.

4. Side effects may include: light-headedness, headache, dizziness, visual disturbances, amnesia, and nausea. In some people, oral Halcion may not work as desired.

5. Smokers will probably notice a decrease in the medications ability to achieve desired results.

6. You should not eat heavily prior to your appointment. You may take the medication with a small amount of food such as juice, toast, etc. Taking it with too much food can make the absorption into your system unpredictable.

7. Bring your additional pills to your appointment so that Dr. Hegle may administer more if needed.

8. On the way home from your appointment, your seat in the car should be in a reclined position. When at home, lie down with your head slightly elevated. Someone should stay with you for the next several hours because of possible disorientation and possible injury from falling.

I understand these considerations and am willing to abide by the conditions stated above. I have had an opportunity to ask questions and have had them answered to my satisfaction.