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I. Purpose

This form, Notice of Privacy Practices, presents the information that federal law requires us to give our patients regarding our privacy practices.

We must provide this notice to each patient beginning no later than the date of our first service delivery to the patient, including service delivered electronically, after April 14, 2003. We must make a good-faith attempt to obtain written acknowledgement of receipt of the notice from the patient.

We must also have the notice available at the office for patients to request to take with them. We must post the notice in our office in a clear and prominent location where it is reasonable to expect any patients seeking service from us to be able to read the notice. Whenever the notice is revised, we must make the notice available upon request on or after the effective date of the revision in a manner consistent with the above instructions.

Thereafter, we must distribute the notice to each new patient at the time of service delivery and to any person requesting a notice. We must also post the revised notice in our office as discussed above.

II. Privacy Practices

Parents or Guardians are encouraged to be in the treatment area during the initial exam so they may become acquainted with the dental office and its personnel, and have the opportunity to review treatment needs with the Specialist.

At subsequent appointments, the presence of the parent or guardian in the treatment area will be established depending on the patient’s needs. Parents or guardians are routinely asked to escort/accompany special needs children and children 3 years of age or younger. We discourage other children being allowed in the treatment rooms while siblings are receiving their dental care. This is done to ensure your child receives the best care under optimal and safe conditions.

Our notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected healthcare information, and of other important matters about your protected health information.

By entering at Petit Smiles you sign an agreement in where you give to Dr. Carla Vanessa Ruiz and her staff authorization to take any x-rays, records, and photographs deemed necessary for the treatment of my child.

You acknowledge that all original records and diagnostic aids are the property of Petit Smiles. Copies may be furnished upon written request based on established policies of the office. There is a small duplication fee.

You also acknowledge that all original records and diagnostic aids are the property of Petit Smiles. Copies may be furnished upon written request based on established policies of the office.

We request your permission for the following dental procedures which include, but are not limited to, the use of local anesthesia (Xylocaine or Septocaine), nitrous oxide, a comfortable mouth prop (tooth pillow) and the placement of dental restorations and/or appliances as required to return teeth to health and proper function.

The dental appointment presents the young child with many new and unfamiliar experiences. It is completely normal for some children to react to these new experiences by crying. Verbal encouragement using a simple explanation (tell-show-do) and positive reinforcement (a prize for being a good helper) are used first. If these approaches are unsuccessful, it is sometimes necessary for the dentist to speak firmly to the child to gain his/ her attention (voice control). Occasionally, it is also necessary to use some form of physical restraint to protect the child from self injury.

The dental environment is full of potential hazards for children; there are sharp objects that must be used near the face and eyes of our young patients during treatment. Most commonly used is a passive arm placed across the child for a short duration.

You also understand that photographs and video may be taken in any of the procedures and that they may be viewed by various personnel undergoing training or indoctrination at this or other facilities. We request you to be consent to the taking of such pictures and observation of the procedure by authorized personnel, subject to the following conditions:

The name of the patient and his/her family is not used to identify the pictures. The picture is used only for medical/dental study or research. I agree/do not agree to allow a picture to be on new patient board in the clinic

We reserve the right to change our privacy practices as described in our notice of privacy practices. If we change our privacy practices, we will issue a revised notice of privacy practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our notice of privacy practice at any time by contacting: Phone: (800) 895-1570 Address: 1535 Sunset Drive Coral Gables, FL 33143

III. Financial Policy

  1. All patients are expected to make payment on the day of service, or have approved financial/payment arrangements made.
  2. For patients covered by insurance, we will accept assignment of benefits. This means you must sign the portion of your insurance form that assigns payment to our office. Most policies do not cover 100% of the cost of your treatment. You will be asked to pay the deductible, if any, and your portion of the charges the day treatment is received. This portion is just an estimate. We will assist you in dealing with the insurance company, but ultimately the responsibility lies with you. If, after 60 days, the insurance company hasn’t paid, the balance will be due, in full, by you.
  3. Patients that currently have a balance with our practice will be asked not to incur any additional dental expense until the balance is paid in full or a payment arrangement has been made.
  4. To avoid increased fees to all patients, if after 90 days from the original date of billing, any balance remains unpaid, we will assess both:
    1. A monthly late fee equal to 0.5% of the total unpaid balances per month (6% per year).
    2. A one-time administrative fee equal to 35% of the total unpaid balance.

    These fees reflect the actual costs incurred by Petit Smiles Pediatric Dentistry to collect amounts owed under the agreement we request you to get signed. All accounts that are turned over for collections are closed. In the event an account is subsequently paid in full, Petit Smiles Pediatric Dentistry at its sole discretion may allow dental care to resume.

  5. In the event that Petit Smiles Pediatric Dentistry needs to submit your account to a collection agency or law firm for recovery, you are responsible for all attorneys’ fees or other costs of collections necessary to collect any amounts due to Petit Smiles Pediatric Dentistry under this agreement.
  6. At the end of each billing cycle, if your account has a credit balance of more than $50.00, our staff will contact you to determine if you would like a refund check or maintain a credit balance. If the credit balance is less than $50.00, it will remain as a credit.
  7. There will be a $50.00 return fee for all returned checks. You agree that your check, as well as any associated fees allowed by Florida law, may be electronically represented. If your account has a returned check, we will no longer be able to accept checks as a form of payment on your account. Additionally, please be aware that any check returned as Account Closed may be referred to the proper authorities for criminal prosecution.

IV. Right to Revoke

You will have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the address listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation, and that we may decline to treat you if you revoke this consent.

V. Social Networks

As you browse and other websites, online ad networks we work with may place anonymous cookies on your computer, and use similar technologies, in order to understand your interests based on your online activities, and thus to tailor more relevant ads to you. If you do not wish to receive such tailored advertising, you can visit this page to opt out of most companies that engage in such advertising. (This will not prevent you from seeing ads; the ads simply will not be delivered through these targeting methods.)