Post on 19-Jul-2020
2335KNOBCREEKROAD,SUITElO7
JOHNSONCllYTENNESSEE37604(423)282-1030
FAX(423)282・4714
www.chadiohnsondds.com
ChadE.Johnson&JoshuaO’Dell
D.D.S.
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CHADJOHNSON,D〟D。S.,P〟C・FAMILY&COSME77CDEN77STRY
2335KnobCreekRoad,SuitelO7
Johns°nCity,TN37604
Teiephone:(423)282-1030
Fax:(423)282-4714
FINANCIALAGREEMENTPOLICY
Toreduceouradministrativecostsandkeepourfeestoyouaslowaspossible・WeaSkthatyoupay
foralIservicesrenderedatthedayofyourappointment・一fyouhavedentalinsurance・Pieasepay
your聾唖塑PerCentageatthetimeyoureceivetreatment・AnybaIanceover60daysw冊e
subjecttofinancechargesattherateofl・5%perm。nth・Returnedcheckfeeis$25・00・
pleaseindicatebel0Wthemethodofpaymentyouintendtousetopayforyourdentaltreatment・
includingyourco-Payment・
PAYMENTOPTIONS
Cashorcheck
VisaorMasterCard
ElectronicFunds(DebitCard)
EXTENDEDPAYMENTOPTIONS
CareCredit(ApprovaiRequired)
APPOINTMENTCANCELATIONPOLICY
ourgoa-istohe-pyouachieveandmaintainahealthyandattractivesmile・lnordertoaccompIishthis・
itisimpohantthatyoukeeptheappointmentsreservedforyou一丁。betterSerVeOurPatientswerequlre
a48hourcanceiIationpo-icy・ifyouareunabletog-VemOrethana24hournoticeofanappointment
cancelIationorfaiItonotshowforyourreservedappointment3timesina12monthperiod・WereSerVe
therighttodismissyoufromthepractice・
MISSEDAPPOINTMENTPOLICY
1.FortheFIRSTmissedapp0両ment;(ina12monthperiod)wew冊rytoassistinrescheduIing
theappointmentatatimewhichmaybe-eas川kelymissed)forgottenorinterrupted・
2.F。rtheSECONDmissedappointment(ina12monthperiod),yOuWⅢreceiveaIetterfromour
oHicestressingtheimportanceofyourdenta-hea-thandthepotentialheaithreIated
consequencesfordelay-ngdenta-treatment・AIsoreinforc-ngOurmissedappo血mentpoiicy・
3.1faTHIRDmissedappointmentshou-doccurwithina12monthperiod)OurO冊cew冊Ot
reschedu-eyouforanotherappointment・Thismayresu-tindismissalfromthepractice・Wewiii
assesseachonacasebasedoncircumstances・
Amissedappointmentisanycance一一ationornoshowwithIessthan24hours’notice・
PrintNameofPatientorResponsible PaHy SignatureofPatientorResponsibIePahy
Reviewedby
MarketingHeam-RelatedServices:We画tinotuseyourheaIthinfomationformarketingcommunications
Withoutyourauthorization.
RequiredbyLaw:Wemayuseordiscioseyourhealthinfomationwhenwearerequiredtodosobylaw・
AbuseorNeglect:Wemaydiscloseyourheai廿日nformationtoapprOPriateauthoritiesifwereasonabIybeIieve
thatyouareapossibievictimofabuse,neglect,domesticvioience・Orthepossibievictimofothercrimes・Wemay
discIoseyourhealthinfomationtomeextentnecessarytoavehaseriousthreattoyourhea柵OrSafety・Orfor
thehealthorSafetyofothers.
AppointmentReminders:WemayuseordiscIoseyourhea冊infomatbntopr0Videyouwithappointment
reminders(SuChasvoi∞mailmessages,teXtmeSSageS,e-maiI.Postcards,OrletterS)・
PatientRiqhts
Access:YouhavetherChtt0100katorget∞PleSOfyourhea剛infomation,Withlimitedex∞PtionsiYoumay
requestthatweprovide∞PleSinafomatotherPhoto∞P-eS・Wew川usethefomatyourequestunlesswe
cannotpracticabiydoso・Youmustmakearequestinw両ngt00btainaccesstoyourheaith而ormation・You
mayobtainafomtorequestac∞SSbyus-ngthecontactinfo…ationIistedattheendofthisNotice・Youmay
aisorequestac∞SSbysendingusalettertotheaddressattheendof帥SNoti∞・WeMIlnotchargeyoufor
expensessuchascopleSandstafftime・Ifyouprefer,We面IIprepareasummaryoranexplanationofyourheaIth
information.
DisciosureAccounting:YouhavetherChttoreceiveaIistofinstancesinwhichweorourbusinessassociates
disciosedyourheaIthinformationforpurposes,OtherthantreatmentIPaymenthealthcareoperationsandcertain
otheractivitiesforthelast6years,butnotbeforeAp川14,2003・lfyourequestthisac∞untingmorethanoncein
a12-mOnthperiod,WemayChargeyouareasonable,COSt-basedfeeforrespondingtotheseadditionaIrequests・
AitemativeCommunication:Youhavetherighttorequestthatwe∞mmunicatewithyouaboutyourhea冊
informationbyaltemativemeansortoaltemativeIocations・YoumustmakevourreclueStinwrmnq・Yourrequest
mustspecifytheaItemativemeansorlocation,andprovidesatisfactoryexplanationofhowpaymentswilIbe
handIedundertheaItemativemeansorloc∈油onyourequest・
Res帥ction:YouhavetherighttorequestthatwepIaceadc囲0nairestrictionsonOuruSeOrdisciosureofyour
heal廿日nformation.Wearenotrequiredtoagreetotheseadditionalresthctions,bu白fwedo,WeWilIabidebyour
agreement(ex∞Ptinanemergency)・
Amendment:Youmayhavetherighttorequestmatweamendyourhealthinfomation・Yourrequestmustbein
Writing,anditmustexpIainwhytheinfomationshouldbeamended・Wemaydenyyourrequestundercehain
Circumstances.
QuestionsandCompIaints
IfyouwantmoreinfomatbnaboutourpnVaCyPraCtCeSOrhavequestionsor∞n∞rnS・Please∞ntaCtuS・
Ifyouare∞nCemedthatwemayhavevioiatedyourprNacyrightsoryoudisagreew柵adecisionwemade
aboutaccesstoyourheaIthinformationorinresponsetoarequestyoumadetoamendorrestricttheuseor
discIosureofyourhealthinfomationortohaveus∞mmunCateWithyoubyaitemativemeansorataItemative
iocations,yOumay∞mPlaintousus一ngthe∞ntaCtinfomatb賀川Stedattheendof肌sNotice・Youalsomay
Submitavt〃皿encomplaintotheU.S.Depa巾mentofhealthandHumanServices・We面目provideyouw冊十me
addressto刷eyour∞mPlaintwiththeU・S・DepammentofHea皿andHumanServi∞SuPOnrequeSt・
Wesupportyourrighttothepr-VaCyOfyourheaith而omation・Wewilinotretaliateinanywayifyouchooseto
軸ea∞mPIaintw肌usorwiththeU・S・DepartmentofHeaithandHumanServi∞S・
Contactinfomation:
ContactO冊cer:JessicaM00re
TeIephone:423T282-1030 Fax:423-282-4714
Address:2335KnobCreekRoad,Suite107.JohnsonCity,TN37604
C哩ohmson,D.D・S・,P・C・
Josh他言.ODeILD・D・S・
2335KnobCreekRoad,SuitelO7
JohnsonCity,TN37604
TeIephone:(423〉282-1030
Fax:〈423)282-4714
DisclosureofPatientinformation
Thispracticedisciosesinformationregardingyourtreatmentt00therhealthcareprofessionalsandinsurance
COmPanies,aSneededfortreatmentandforPaymentfortreatment・Ifinformationisrequestedbypersonsother
thanheaithcareprofessionaisandinsurancecompanies,thispracticew用onlydiscIosedentaitreatmenttothe
authorizedpersonsnamesbelow.Itisyourresponsib冊ytoinformusofanychangestothisinformation・
lglVePermissionforDr・JohnsonandDr・○)Deiland/OrhisempIoyeestodiscioseinforegardingtreatmenttothe
foIIowingperson(S):
Name(PleasePrint)
Name(PleasePrint)
Name〈PleasePrint)
Name〈PleasePrint)
Name(PIeasePrint)
Nameofpatient
SignatureofPatientorParentIGuardian
Reiationship
Relationship
ReIationship
ReIationship
ReIationship