Privacy Statement
Office Policy

Welcome to Q-Dental Group, P.C. We are proud to offer all the benefits of modern group dentistry and the personal attention of your own individual dentist. Our group efficiency allows us to keep our fees moderate.

Coverage Accepted
We accept all dental insurance plans and we participate directly with many insurance companies. If you have coverage under one of these plans, we will submit your claims automatically and accept assignment of payment. You will be responsible for all co-payments and/or deductibles at the time of your visit. It is your responsibility to know your own dental insurance plan benefits and limitations. You will also be responsible for the balance of any procedure recommended and performed by your dentist or hygienist that your insurance company does not recognize as a covered procedure. There will be a finance charge of 1.5% monthly on any balances over 90 days old.

If you have the benefit of coverage under two dental plans, please notify our office. It may eliminate any out-of-pocket cost to you and maximize your insurance benefits.

Payment Options
For your convenience, we accept cash, checks, MasterCard, VISA, and DiscoverCard. CareCredit payment options are also available. There will be a $20 fee for all checks that are returned for insufficient funds. Failure to complete treatment does not absolve you from any financial responsibilities. In the event that it becomes necessary for Q-Dental to pursue civil remedies to collect financial obligations for services rendered, you will be responsible for reasonable collection and/or attorney fees.

Notifications About Changes
Please notify our office of any change in your health, medications, marital status, address, phone number, or dental insurance when applicable. If you are unable to keep a scheduled appointment, our office requires a 24-hour cancellation notice. If you cancel or miss two or more appointments without 24-hour notice, there may be a $20.00 to $50.00 cancellation fee applied before you can be rescheduled. Also, please notify us if you have ever been seen at one of our other locations.

Children's Appointments
Children under the age of 18 should be accompanied by an adult or guardian at the time of their visit. If you are unable to attend with your child, please provide a number where you can be contacted regarding necessary treatment.

HIPAA STATEMENT

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.

The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. The Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.

As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

We may use and disclose your medical records only for each of the following purposes: treatment, payment and healthcare operations.
• Treatment means providing, coordinating, or managing healthcare and related services by one or more healthcare providers. An example of this would include teeth-cleaning services.
• Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.
• Healthcare operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost management analysis, and customer service. An example would be an internal quality assessment review.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:
• The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
• The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
• The right to inspect and copy your protected health information.
• The right to amend your protected health information.
• The right to receive an accounting of disclosures of protected health information.
• The right to obtain – and we have the obligation to provide you – a paper copy of this notice from us at your first service delivery rate.
• The practice will provide you – and is obligated to receive from you a written acknowledgement that you have received a copy of our Notice of Privacy Practices.

We are required by law to maintain the privacy of your protected health information and to provide you with notice of your legal duties and privacy practices with respect to protected health information.

This notice is effective as of January 1, 2003; we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post – and you may request – a written copy of a revised Notice of Privacy Practices from this office.

You have recourse if you feel that your privacy protections have been violated. You have the right to file a formal, written complaint with us at the address below, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.

Please contact us for more information:
Privacy Officer
Q-Dental Group, P.C.
1100 Long Pond Road
Country Village Plaza
Rochester, NY 14626
(585)-225-7790

For more information about HIPAA or to file a complaint, contact:
The U.S. Department of Health & Human Services
Office of Civil Rights
Washington, D.C. 20201
(202)-619-0257
Toll-Free: 1-877-696-6775