Do you have or have you had any of the following:

Are you allergic to?

All services are rendered and accepted under the terms and conditions printed on the reverse hereof:

Authorization must be signed by the patient, or by the nearest relative in the case of a minor or when the patient Is physically or mentally incompetent To the best of my knowledge, all of the preceding answers are true and correct If I ever have any change In my health or If my medications change, I will , without fail, inform the doctor at my next appointment

Thank you for choosing us as your dental health care providers! Our goal is to provide you and your family with optimal dental care. We want you to feel welcome and as comfortable as possible throughout our relationship. We encourage you to ask questions and to be involved in treatment decisions. This includes understanding your treatment plan as well as our financial policy.

Our primary goal is to provide you with the personalized, quality care you deserve and to deliver a smile you truly love. As part of our commitment to you, we will make every effort to make the cost of treatment affordable and will insure you receive the quality care you need or desire. We strive to help you understand your insurance plan and the benefits available to you and make it possible for you to receive your maximum insurance benefits available. Our policy is to calculate, estimate and inform you of all possible costs before we perform any treatment. Our fees are based on the quality materials we use and the time, effort and skill required in performing your needed treatment. We abide by fees that are the usual and customary rates for our area. We will be sensitive to your financial circumstances and do everything possible to help you achieve optimal oral health. Ultimately, however, you are responsible for payment regardless of your insurance company's arbitrary determination of usual and customary rates and any coverage limitations.

Financial Agreement

Treatment plans are good 6 months from the date issued. After that period fees and financial arrangements are subject to change.

Patients are expected to pay for our services at the time they are rendered. Our patients who have dental insurance are expected to pay the amount of their estimated co-pay and deductible at the time of service.

Treatment can change due to unforeseen and unpredictable circumstances that can arise once a procedure is started. There will be a fee for any additional procedure NOT included in the original treatment plan.

Payments may be made using cash, check, or credit card. We also partner with CARECREDIT and THE LENDING CLUB to offer additional financing options to our patients. Ask for an application.

Optional payment terms

1. Pay in full cash discount: We offer a 5% accounting courtesy for all services over $500 that are paid in full on the date of service for those who do not have dental insurance.
2. Pre- Pay discount: If you choose to prepay for services 48 hours prior to your reserved appointment we will extend a 10% courtesy discount with cash or check. A minimum of $1500 patient portion is required. Available for those patients who do not have dental insurance.
3. In office payment plan: We offer a courtesy 3 month interest free automatic payment plan with a credit card on file. Arrangements must be made prior to your reserved appointment.
4. Term Loan: By arrangements with CARECREDIT and/or THE LENDING CLUB we can offer patients upon approval, an interest-free term loan (up to 24 months) with no down payment, no annual fee and no prepayment penalty.

For our patients with Insurance

As a courtesy to our insured patients, we obtain your plan benefits and submit claims to your insurance company free of charge. We are here to help you receive your maximum benefit available.

However, if your insurance company has not reimbursed our office within 90 days of services rendered, you, the patient, are then responsible for any outstanding balance.

We urge our patients to follow up and pursue any outstanding claims 90 days or older. We find that when the patient gets involved with their pending claims the insurance company tends to be more responsive. We will provide you with all current documentation in order to assist you with your inquiries.

If you visit another office, whether it be for an emergency or a referral, it is your responsibility to notify our office of any insurance used in that office and any plan or benefit changes.

We will mail monthly statements to all patients with an outstanding balance including a charge of 1.5% per month after 60 days.

I hereby authorize my insurance company to directly reimburse Redondo Beach Dental Group for services rendered to me under my insurance policy.

Appointments

In order to serve you better and keep the cost of dental care down, we try to maintain an efficient appointment system. However, our cost of providing care increases greatly when people fail to keep scheduled appointments or cancel at the last minute.

When you schedule an appointment at our office, we consider it a commitment that the time will work with your schedule. If a scheduled appointment will not work as you had planned, we appreciate and anticipate that you will contact us as soon as possible. We request a 48 business hour notice which will allow us enough time to appoint another patient in your place. We reserve the right to charge a fee if this policy is not respected and we are unable to appoint another patient waiting for care or if you miss your appointment. Hence, there may be a fee of $60 for each hour of the total appointment time missed or cancelled inside a 48 business hour notice.

We do not penalize for unavoidable situations and emergencies. However, we do want to strongly discourage repeated abuse of our scheduling process out of respect for our doctors, assistants and hygienists who are ready and expecting you. After 3 missed or cancelled appointments we may request you seek your dental care elsewhere.

We will attempt to communicate with you in multiple ways to remind you of your reserved appointments. We will mail postcards one month prior to your regular recall and hygiene visits, email you one week prior to your appointment and call or text, if you so choose, 48 and 24 hours before your appointments. If you confirm your appointment online we will forgo calling you directly. We always appreciate you taking a moment to return our calls to let us know that we can count on you to be at your reserved appointment.

If you have any questions about this policy please do not hesitate to let us know, as we welcome any and all communication.

Please indicate your understanding and acceptance of these scheduling and financial policies by signing below.

Patient Arbitration Agreement

Article1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering in, are giving up their constitutional rights to have any such dispute in a court of law before a jury, and instead are accepting the use of arbitration.

Article2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims any arise out of or relate to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expectant child or children.

All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician’s partners, associates, association, corporation or partner shup, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for the loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim.

Article 3: Procedures Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed parties within thirty days of a demand for a neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counseling fees or witness fees, or expenses incurred by a party for such party’s own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, nor supplant, any other applicable statutory or common law.

Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator.

The parties consent to the intervention and joinder in the arbitration of any person or entity, which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration

The parties agree that provisions of California law applicable to health care providers shall apply to disputes with this arbitration, including but not limited to, Code of Civil Procedure Section 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring before the arbitrators a motion for summary judgment or summary adjunction in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure section 1283.05: however, depositions may be taken without prior approval of the neutral arbitrator.

Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received the claim, if asserted in a civil action, would be barred by the applicable California statue of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration.

Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of signature. It is the intent of this agreement to apply to all medical services rendered at any time for any condition.

Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below: __________

Effective as of the date of the first medical services.

If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.

I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy.

NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

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 cf 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. This act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for cover entitles 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 health care operations.

- Treatment means providing, coordinating or managing health care and related services by one or more healthcare providers. An example of this would Include teeth cleaning services.

- Payments 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.

- Health care 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 appointments reminders or Information about treatment alternatives or other health-related benefits and services that may be Interested 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 request to receive confidential communications of protected health information from us by alternative means or alternative locations.
• The right to Inspect and copy your protected health Information.
• The right to amend your protected health information.
• The right receive and accounting of disclosures of protected health information.
• The right to obtain a paper copy of this notice form upon request.

This notice is effective as of 11-18-2015 and 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 Practice 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 protection has been violated. You have the right to file a written complaint with our office, 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.

You have recourse if you feel that your privacy protection has been violated. You have the right to file a written complaint with our office, 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.

For more information about HIPAA or to file a complaint:

The US Department of Health & Human Services
office of Civil Rights
200 Independence Avenue, S. W.
Washington, D.C. 20201
Toll Free: 1-877-696-6775

I understand that. under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
• Obtain payment from third-party payers.
• Conduct normal healthcare operations such as quality assessments and physician certifications.

I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or Disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.