OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 20, 2003 and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations.
PERSONS INVOLVED IN CARE
We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
REQUIRED BY LAW
We may use or disclose your health information when we are required to do so by law.
We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.
We may use or disclose your health information to provide you with appointment reminders.
QUESTIONS AND COMPLAINTS
If you would like more information about our privacy practices or have questions or concerns, please contact us: Heidi Ballard, (603) 225-6331, 9 Triangle Park Drive, Suite 3, Concord, NH 03301
GDC asks for 24 hours notice should you need to cancel an appointment (excluding family emergencies).
To help reduce our administrative costs and keep our fees to you as low as possible, we require payment to be made at or prior to the time that you (or your family members) receive treatment. The payment methods available to you are:
For treatment plans over $300, please inquire about the possibility of an extended payment plan.
A note for patients with dental insurance-
Dental insurance usually does not cover the total cost of your treatment. When treatment is delivered to you, your co-payment will be expected at that time. If your insurance company fails to pay within 60 days after we submit your claim, you will be responsible for the full fee.
RETURNED CHECK POLICY
In cases where checks are returned due to insufficient funds, GDC will charge the patient’s account a service fee to cover administrative expenses. If the bank allows, we will re-deposit the check. If the bank does not allow this, or if the check is returned again, we will contact you to work out alternative payment arrangements such as MC/VISA, cash or independent financing. This fee must be paid prior to the family’s next scheduled appointment.
The privacy of your health information is important to GDC. By signing this form you acknowledge that you have received and read a copy of GDC's Privacy Practices. The Privacy Practices form describes how health information about you may be used and disclosed and how you can get access to this information.
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