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Thank you for choosing Dr. Negari for your dental needs. To better serve you, we would like to explain the dental billing process at our office. Once you provide the office with your dental insurance we call your insurance company and verify your benefits. The information we receive from your insurance company is only an estimation of coverage and not a guarantee. After you have been seen in our office we will file your claim to the insurance company directly. If the insurance company does not cover the estimated amount in full, you will receive a statement in the mail and be responsible for the remaining account balance.

We make every effort to help you optimize your insurance. We will estimate your co-insurance based on the information obtained from your benefit company. At the time of your treatment, it's your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. Our office does not extend credit for dental care. Other arrangements can be discussed with our office manager before the start of treatment. An estimate of the charges for any procedure you may require will be given to you upon request.

We ask that you call our office and kindly give us at least 48 hours notice to reschedule your appointment. Appointments that are canceled with less than 24 hours notice are considered a broken appointment and may be subject to a cancellation fee of $50 for a hygiene appointment, and $65 per hour for appointments with Dr. Negari. Our goal is to provide treatment in a timely manner with as few visits as necessary. We make every effort to remind you of your appointment ahead of time. We understand that last minute changes in your schedule may be unavoidable and we will try to accommodate those changes as best we can.

Federal and state laws require us to maintain the privacy and security of your nformation. We are also required to provide this Notice ractice’s privacy practices, our legal duties, and your our health information. We must follow the duties and that are described in this Notice while it is in effect and it. This Notice takes effect on 03/25/2014 and will remain replace it. We will not use or share your information other here unless you tell us we can in writing. If you tell us we e your mind at any time by informing us, using the contact

We reserve the right to change our privacy practices and the terms of this , provided such changes are permitted by applicable law. ignificant change in our privacy practices, we will change ke the new Notice available upon request. New terms of our ective for all health information that we maintain, nformation we created or received before we made the

We typically use or share information in the following ways:

Treatment:

We may use your health information and share it with our employees and other professionals who are treating you. We may use or disclose your health ther health care provider. Examples include: sharing your Dental information with a doctor asks your former doctor about your previous treatments, with a laboratory that performs ses or orthodontic appliances, with a pharmacist to provide you with a prescription, or with e specialist to provide you with services not offered by our practice.

Payment:

We may use and share your health information to bill and receive payment from health plans or other entities unless you request that we restrict such disclosure to your health plan when you have paid out-of-pocket and in full red.

Healthcare Operations:

We may use and disclose your health information about our healthcare operations. Healthcare operations include activities related to running our practice, improving your care, and contacting you, when necessary. Healthcare clude using health information about you to manage your treatment and services. Some examples e not limited to, engaging in quality assessment and improvement activities; reviewing the ifications of healthcare professionals; evaluating practitioner and provider performance; ing programs, accreditation, certification, licensing or credentialing activities.

Public Health:

We may, and are sometimes legally obligated to, disclose your health information to public health agencies for purposes related to preventing or controlling disease, injury, or disability; reporting abuse or neglect; violence; reporting to the Food and Drug Administration problems with products and reactions and reporting disease or infection exposure.

Abuse or Neglect:

We may disclose your health information to the appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or or the possible victim of other crimes. We may disclose your health information to the extent ert a serious threat to your health or safety or the health or safety of others.

National Security:

We may disclose health information about you for specialized government functions such as military, national security, and presidential protective isclose to authorized federal officials health information required for lawful intelligence, nce, and other national security activities. We may disclose to correctional institutions or als having lawful custody of protected health information of inmates or patients under ances.

To Comply with the Law:

We will share information about you if a state or federal law requires it. This includes disclosures to courts upon a court order, to law enforcement ts, or to other government entities with orders pursuant to their respective legal authority artment of Health and Human Services if it we are complying with federal privacy law.

Appointment Reminders:

We may contact you to provide you with appointment reminders via email, text messages, voicemail, postcards, or letters. We may also leave a message with ng the phone if you are not available.

Sign-In Sheet and Announcement:

Upon arriving at our office, we may use and disclose Dental information about you by asking that you sign an intake sheet at our front desk. We may also when we are ready to see you.

To Your Family and Friends:

We must disclose your health information to you, as described in the Patient Rights section of this Notice. You have the right to request restrictions on ly members, other relatives, close personal friends, or any other person identified by you.

Persons Involved in Care:

We may use or disclose your health information to notify, or assist in the notification of (including identifying or locating) a family member, your ative or another person responsible for your care, of your location, your general condition, are present, then prior to use or disclosure of your health information, we will provide you ect to such uses or disclosures. In the event of your incapacity or emergency circumstances, health information based on a determination using our professional judgment disclosing only that is directly relevant to the person's involvement in your healthcare. We will also use judgment and our experience with common practice to make reasonable inferences of your best to pick up filled prescriptions, Dental supplies, X-rays, or other similar forms of health

Marketing Health-Related Services:

We may contact you about products or services related to your treatment, case management or care coordination, or to propose other treatments or health-related benefits and services in which you may be interested. We may to purchase a product or service when you visit our office. If you are currently an enrollee ctice office plan, we may receive payment for communications to you in relation to our anagement of your Dental Practice office care, including our coordination or management of with a third party, our consultation with other health care providers relating to your care, th care. We will not otherwise use or disclose your health information for marketing purposes itten authorization. We will disclose to you whether we receive payments for marketing you

Research:

Your health information may be disclosed to researchers for research purposes. In this situation written authorization is not required as approved by an ew Board or privacy board.

Other Uses and Disclosures of Your Health Information:

Your authorization is required, with a few exceptions, for disclosure of psychotherapy notes, use or disclosure of your health information for marketing, and for the sale of your PHI. We will also obtain your written re using or disclosing your health information for purposes other than those provided for in as otherwise permitted or required by law). You may revoke an authorization in writing at any tten revocation, we will stop using or disclosing your health information, except to the ave already taken action in reliance on the authorization.

Your Authorization:

In addition to our use of your health information for treatment, payment, or healthcare operations and otherwise as described in this Notice, you may give zation to use your health information or to disclose it to anyone for any purpose. If you rization, you may revoke it in writing at any time. Your revocation will not affect any use authorization while it is in effect. Unless you give us a written authorization, we cannot your health information for any reason except those described in this Notice.

Access:

You have the right to see or obtain electronic or paper copies of your Dental ealth information, with limited exceptions. You may request pies in a format other than photocopies. We will use the unless we cannot practicably do so. You must make a request in access to your health information. You may contact our form to request access. We will charge you a reasonable expenses such as copies and staff time. You may also sending us a letter. If you request copies, there may be an sed fee. If you request an alternate format, we will charge or providing your health information in that format. If you epare a summary or an explanation of your health information contact our office to request a copy of your Dental record anation of our fee structure.

Disclosure Accounting:

You have a right to receive a list of instances in which we disclosed your for purposes other than treatment, payment, healthcare tain other activities for the last six years. If you request re than once in a 12-month period, we may charge you a sed fee for responding to these additional requests. You may to request a disclosure accounting.

Additional Restrictions:

You have the right to request that we place additional restrictions on our use our health information. We are not required to agree to tions, but if we do, we will abide by our agreement (except or example, if you pay out-of-pocket and in full for you may request that we not share your health information lan. We must agree to this request. You may contact our additional restrictions.

Alternative Communication:

You have the right to request that we communicate with you about your health ernative means or to alternative locations. You must make iting. Your request must specify the alternative means or de a satisfactory explanation of how payments will be alternative means or location you request. You may contact in a form to request alternative communication. See Patient tions form – (PDI form).

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 eny your request under certain circumstances. You may contact our office to obtain a form to ment.

Breach Notification:

In the event your unsecured protected health information is breached, we will notify you as required by law. In some situations, you may be notified by our s.

Questions and Complaints:

If you want more information about our privacy practices or have questions or concerns, please contact our Privacy Official at:

Contact Name: Dr. Negari
Address: 14495 South Bascom Ave, Los Gatos , CA 95032

If you are concerned that we may have violated your privacy rights, you may send a written complaint to our office. You can also file a complaint with the Health and Human Services. We will not retaliate against you for filing a complaint. This will never condition the provision of treatment or payment on obtaining a waiver from an o file complaints under this section.