Financial Policy ~ HIPAA Policy
For your convenience we accept Visa, MasterCard, Discover and American Express. We deliver the finest care at the most reasonable cost to our patients, therefore payment is due at the time service is rendered unless other arrangements have been made in advance. It is our goal to make dentistry affordable for every patient and we will work with you to provide options to make that happen! If you have questions regarding your account, please contact us at Renton Office Phone Number 425-572-6021. Many times, a simple telephone call will clear up any billing misunderstandings.
Please remember you are fully responsible for all fees charged by this office,
regardless of your insurance coverage.
We will send you a monthly statement. Most insurance companies will respond within four to six weeks. Please call our office if your statement does not reflect your insurance payment within that time frame. Any remaining balance after your insurance has paid is your responsibility. Your prompt remittance is appreciated. We can make arrangements for a monthly payment plan, but this must be done prior to the actual procedure.
This notice describes the policies and procedures of Inspired Dentistry with respect to protecting the confidentiality of your dental/medical information. “Medical information” and “health care,” for purposes of this notice, include your dental information and dental care. Third parties that assist in administration or provision of dental services provided by Inspired Dentistry are contractually obligated to follow the same policies and procedures followed by Inspired Dentistry. These third parties that assist in administration or provision of health care are called “business associates.” Inspired Dentisty, directly and through business associates, maintains medical information about you for medical care and medical administration purposes. This notice will tell you about the ways in which Inspired Dentisty may legally use and disclose medical information in accordance with federal regulations under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). It also describes Inspired Dentistry’s obligations and your rights under HIPAA regarding the use and disclosure of medical information. Inspired Dentisty is required by law to:
make sure that medical information that identifies you is kept private
give you this notice of [Legal Name of Entity’s] legal duties and privacy practices with respect to medical information about you
notify you following a breach of your unsecured medical information
follow the terms of this notice, as amended from time to time
appoint a Privacy Official to make sure Inspired Dentistry satisfies its legal requirements You can contact the Privacy Official at the following address: Inspired Dentistry, 10915 SE Petrovitsky Rd Renton, WA. 98055 425-572-6021 When Inspired Dentistry may use and disclose medical information about you: The following categories describe different times when Inspired Dentistry and its business associates are permitted to use and disclose medical information. Inspired Dentistry and its business associates are not required to obtain your consent to use and disclose your medical THIS NOTICE DESCRIBES HOW DENTAL/MEDICAL INFORMATION ABOUT YOU AND YOUR DEPENDENTS MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY. Inspired Dentistry or its business associates will obtain an authorization from you if they wish to use or disclose your medical information for a purpose not listed in one of the following categories:
i) For treatment: Inspired Dentistry or a business associate may use or disclose medical information about you to facilitate medical treatment or services by providers, including physicians, dentists, nurses, technicians, medical students, or other personnel who are involved in taking care of you. For example, Inspired Dentistry might disclose information about your prior prescriptions to a pharmacist to determine if a pending prescription is incompatible with prior prescriptions.
ii) For payment: Inspired Dentistry and its business associates use and disclose medical information about you to determine benefit payments consistent with the terms of your dental plan. Payment activities include uses and disclosures to determine eligibility for dental plan benefits, to facilitate payment for the treatment and services you receive from Inspired Dentistry, to determine benefit responsibility under your dental plan, and to coordinate benefits with another dental plan that covers the same condition. For example, Inspired Dentistry shares medical information with your dental plan’s administrator to assist with the processing of dental claims and with other health plans to coordinate benefit payments.
iii) For health care operations: Inspired Dentistry and its business associates use and disclose medical information about you for operations that are necessary to run Inspired Dentistry. For example, Inspired Dentistry may use medical information in connection with: conducting quality assessment and improvement activities; submitting claims for coverage; legal services; business planning and development such as cost management; and business management and general administrative activities of Inspired Dentistry.
iv) As required by law: Inspired Dentistry and its business associates will disclose medical information about you when required to do so by federal, state or local law. For example, Inspired Dentistry may disclose medical information to the Secretary of the United States Department of Health and Human Services when the Secretary is investigating or determining Inspired Dentistry’s compliance with the HIPAA privacy rule.
v) To avert a serious threat to health or safety: Inspired Dentistry and its business associates may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. For example, Inspired Dentistry may disclose medical information about you in a proceeding regarding the licensure of a dentist. With certain exceptions, your medical information may also be disclosed in order to assist law enforcement in identifying or apprehending an individual participating in a violent crime, or when an individual has escaped from a correctional institution or other lawful custody. Should these uses or disclosures be necessary, however, Inspired Dentistry will use or disclose your medical information in a manner consistent with applicable laws and ethical standards.
vi) Individuals involved in your care or payment for your care: Inspired Dentistry may disclose your health information to your family or friends or any other individual identified by you when they are involved in your care or in the payment for your care. Additionally, Inspired Dentistry may disclose information about you to a patient representative. If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information.
3 Special situations: Organ and tissue donation: If you are an organ donor, Inspired Dentistry may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation. Specialized government functions:
If you are a member of the armed forces, Inspired Dentistry may disclose medical information about you as required by military command authorities if those authorities have provided proper notice. Inspired Dentistry may also disclose medical information about foreign military personnel to the appropriate foreign military authority.
Inspired Dentistry may disclose your medical information to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.
If you are an inmate of a correctional institution or under the custody of a law enforcement official, Inspired Dentistry may disclose your medical information to the correctional institution or law enforcement official. This disclosure would be necessary (1) for the institution to provide you with health care, (2) to protect your health and safety or the health and safety of others, (3) for law enforcement on the premises of the correctional institution, or (4) for the safety and security of the correctional institution. Workers’ compensation: Inspired Dentistry may release medical information about you as necessary to comply with laws relating to workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness. Public health risks: Inspired Dentistry may disclose medical information about you for public health activities, such as:
preventing or controlling disease, injury or disability, including reporting of health statistics and the conduct of public health surveillance, investigations, and interventions
reporting child abuse or neglect
reporting reactions to medications or problems with products and notifying people of recalls of products they may be using notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition Notifying authorities about victims of abuse, neglect, or domestic violence: Inspired Dentistry may disclose medical information to the appropriate government authority about an individual whom Inspired Dentistry reasonably believes to be a victim of abuse, neglect or domestic violence. Inspired Dentistry will only make this disclosure of your medical information if you agree or when otherwise required or authorized by law. Health oversight activities: Inspired Dentistry may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure, as well as disciplinary, civil, or criminal proceedings or actions. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. Inspired Dentistry may not disclose your medical information under this rule if you are the subject of an investigation that is not directly related to your receipt of health care benefits. 4 Lawsuits and disputes: If you are involved in a lawsuit or a dispute, Inspired Dentistry may disclose medical information about you in response to a court or administrative order. In addition, Inspired Dentistry may disclose information in response to a subpoena, a discovery request, or other lawful process by someone else involved in the lawsuit or legal dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. Law enforcement: Inspired Dentistry may release medical information if asked to do so by a law enforcement official
as required to report certain wounds or other physical injuries
in response to a court order, subpoena, warrant, summons or similar process to identify or locate a suspect, fugitive, material witness, or missing person
to provide information about the victim of a crime if, under certain limited circumstances, Inspired Dentistry is unable to obtain the person’s agreement
to provide information about a death that may be the result of criminal conduct
to provide information about criminal conduct at a hospital or dental office while providing emergency health care in certain circumstances, to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime Coroners, medical examiners and funeral directors: Inspired Dentistry may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. Inspired Dentistry may also release medical information about patients to funeral directors as necessary to carry out their duties. Disclosures that may only be made with your written permission: The following disclosures will be made only with your written permission:
most uses and disclosures of psychotherapy notes
uses and disclosures of your medical information for marketing purposes, including subsidized treatment communications disclosures that would constitute the sale of your medical information
other uses and disclosures not described in this document If you give permission to use or disclose medical information for which an authorization is required, you may revoke the authorization, in writing, at any time. If you revoke your authorization, Inspired Dentistry and its business associates will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that Inspired Dentistry is unable to take back any disclosures that were previously made with your permission, and that Inspired Dentistry is required to retain records of dental services provided to you. Your rights regarding medical information about you: You have the right to know how Inspired Dentistry uses or discloses your medical information. You, or the person you authorize or designate as your personal representative, also have the following rights regarding medical information Inspired Dentistry and its business associates maintain about you: Right to inspect and copy: You have the right to inspect and copy medical information that may be used to make decisions about your dental care through Inspired Dentistry. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to Inspired Dentistry’s Privacy Official. If you request a copy of the 5 information, Inspired Dentistry may charge a fee for the costs of copying, mailing or other supplies associated with your request. Also, if Inspired Dentistry’s maintains your medical information in an “electronic health record,” you can receive a copy electronically or ask Inspired Dentistry to send the record electronically to a third party. The term “electronic health record” means an electronic record of health-related information about you that is created, gathered, managed, and consulted by authorized health care clinicians and staff. Inspired Dentistry may charge you its labor costs associated with complying with your request. Inspired Dentistry may deny your request to inspect and copy medical records in certain limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Right to request amendment: If you feel that medical information Inspired Dentistry or a business associate has about you is incorrect or incomplete, you may ask Inspired Dentistry to amend the information. You have the right to request an amendment for as long as the information is kept by or for Inspired Dentistry. To request an amendment, your request must be made in writing and submitted to Inspired Dentistry’s Privacy Official. In addition, you must provide a reason that supports your request. Inspired Dentistry may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, Inspired Dentistry may deny your request if you ask to amend information that:
is not part of the medical information kept by or for Inspired Dentistry
was not created by Inspired Dentistry, unless the person or entity that created the information is no longer available to make the amendment
is not part of the information which you would be permitted to inspect and copy
is accurate and complete Right to an accounting of disclosures: You have the right to request an accounting (or listing) of any disclosure that was made for any purpose other than treatment, payment, or health care operations, as described above.
To request this list or accounting of disclosures, you must submit your request in writing to Inspired Dentistry’s Privacy Official. Your request must specify a time period, which may not be longer than six years from the date of your request. Your request should indicate in what form you want the list (for example, paper or electronic). The first list you request within a 12-month period will be provided free. For additional lists, Inspired Dentistry may charge you for the costs of providing the list. Inspired Dentistry] will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. Right to request restrictions on use or disclosure: As an exception to the general rule of use and disclosure, you have the right to request a restriction or limitation on the medical information Inspired Dentistry and its business associates use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information Inspired Dentistry and its business associates disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that Inspired Dentistry] not use or disclose information about a surgery you had. Except in limited circumstances, 6 Inspired Dentistry is not required to agree to your request. Inspired Dentistry is required to comply with your request to restrict disclosures of your medical information if the information relates solely to a health care item or service for which you paid in full, and if the disclosures are for the purpose of carrying out a payment or health care operation and are not otherwise required by law. To request restrictions, you must make your request in writing to Inspired Dentistry’s Privacy Official. In your request, you must explain (1) what information you want to limit; (2) whether you want to limit use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse. Right to request confidential communications: You have the right to request that Inspired Dentistry and its business associates communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that Inspired Dentistry contact you only at work or only by mail. To request confidential communications, you must make your request in writing to Inspried Dentistry’s Privacy Official. Inspired Dentistry will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a paper copy of this notice: You have the right to a paper copy of this notice. You may ask for a paper copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice, contact Inspired Dentistry’s Privacy Official. Right to be notified of any breach: Inspired Dentistry is required by law to notify you of any breach of the privacy or confidentiality of your unsecured medical information. Changes to this notice: Inspired Dentistry reserves the right to change this notice to reflect changes in its privacy practices, both for medical information Inspired Dentistry and its business associates already have about you, as well as any information received in the future. This notice will be revised to reflect any changes to Inspired Dentistry’s privacy practices, and will be provided to you within 60 days of the change. All privacy notices will indicate the effective date at the top of the first page. Complaints: If you believe your privacy rights have been violated, you may file a complaint with Inspired Dentistry or with the Secretary of the Department of Health and Human Services. To file a complaint with Inspired Dentistry, contact the Privacy Official. All complaints must be submitted in writing. You will not be penalized or retaliated against if you file a complaint. More information: For more information about this notice and the uses and disclosures of medical information, please contact: Inspired Dentistry, 10915 SE Pewtrovitsky Rd, Renton Wa 98055. 425-572-6021 45 CFR 164.520, 45 CFR 164.530(i), 45 CFR 164.502(i) 11/15