I authorize Carolinas Center for Oral & Facial Surgery to release any information for insurance purposes. I hereby authorize payment directly to Carolinas Center for Oral & Facial Surgery.

I certify that the information on this form is correct. I understand that I am responsible for my balance on this account, even if I have medical and/or dental coverage.

Carolinas Center for Oral & Facial Surgery is authorized to release protected health and/or financial information about the named patient below in the following manner and to identified persons.

The entity to Receive Information.

Write each person/entity that you approve to receive information.

Patient Rights:

• I have the right to revoke this authorization at any time.
• I may inspect or copy the protected health information to be disclosed as described in this document.
• Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
• Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.

You will sign this portion of your paperwork during your in-office visit

EFFECTIVE AUGUST 30, 2022

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.

UNDERSTANDING YOUR HEALTH RECORD/INFORMATION

Each time you visit a healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information is often referred to as your health or medical record and serves as a basis for planning your care, treatment, and a means of communication among the many health professionals who contribute to your care. Understanding what is in your record and how your health information is used helps you to ensure its accuracy, better understand when others may access your health information and for what purpose, and helps you make more informed decisions when authorizing disclosure to others.

YOUR HEALTH INFORMATION RIGHTS

Unless otherwise required by law, your health record is the physical property of the healthcare practitioner or facility that compiled it. However, you have certain rights with respect to the information. You have the right to:

1. Receive a copy of this Notice of Privacy Practices from us upon enrollment or upon request.
2. Request restrictions on our uses and disclosures of your protected health information for treatment, payment, and health care operations. We have the right not to agree to a given requested restriction unless it pertains to a request that we do not disclose your health information to a health reserve plan for payment or health care operations and that you have paid in full and out of pocket for the services provided.
3. Request to receive communications of protected health information in confidence.
4. Inspect and obtain a copy of the protected health information contained in your medical and billing records and in any other Practice records used by us to make decisions about you. If we maintain or use electronic health records, you will also have the right to obtain a copy or forward a copy of your electronic health record to a third party. A reasonable copying/labor charge may apply.
5. Request an amendment to your protected health information. However, we may deny your request for an amendment, if we determine that the protected health information or record that is the subject of the request: (i) was not created by us unless you provide a reasonable basis to believe that the originator of the protected health information is no longer available to act on the requested amendment; (ii) is not part of your medical or billing records; (iii) is not available for inspection as set forth above; or (iv) is accurate and complete. In any event, any agreed-upon amendment will be included as an addition to, and not a replacement of, already existing records.
6. Ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, health care operations, and certain other disclosures (such as any you asked us to make
7. Revoke an authorization to use or disclose health information except to the extent that we have already taken action in reliance on your authorization, or if the authorization was obtained as a condition of obtaining insurance coverage and other applicable law provides the insurer that obtained the authorization with the right to contest a claim under the policy.
8. Receive notification if affected by a breach of unsecured PHI.

HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED

This organization may use and/or disclose your medical information for the following purposes:

Treatment: We may use and disclose protected health information in the provision, coordination, or management of your health care, including consultations between health care providers regarding your care and referrals for health care from one health care provider to another.

Payment: We may use and disclose protected health information to obtain reimbursement for the health care provided to you, including determinations of eligibility and coverage and other utilization review activities.

Regular Healthcare Operations: We may use and disclose protected health information to support functions of our practice related to treatment and payment, such as quality assurance activities, case management, receiving and responding to patient complaints, physician reviews, compliance programs, audits, business planning, development, management, and administrative activities.

Appointment Reminders: We may use and disclose protected health information to contact you to provide appointment reminders. Treatment Alternatives: We may use and disclose protected health information to tell you about or recommend possible treatment alternatives or other health-related benefits and services that may be of interest to you.

Health-Related Benefits and Services: We may use and disclose protected health information to tell you about health-related benefits, services, or medical education classes that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care: Unless you object, we may disclose your protected health information to your family or friends, or any other individual identified by you when they are involved in your care or the payment for your care. We will only disclose the protected health information directly relevant to their involvement in your care or payment. We may also disclose your protected health information to notify a person responsible for your care (or to identify such person) of your location, general condition, or death.

Business Associates: There may be some services provided in our organization through contracts with our service providers, called Business Associates. Examples may include billing services, or cloud storage vendors. When these services are contracted, we may disclose some or all of your health information to our Business Associates so that they can perform the job we have asked them to do. To protect your health information, we require all Business Associates to appropriately safeguard your information and comply with HIPAA.

Organ and Tissue Donation: If you are an organ donor, we may disclose 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.

Worker's Compensation: We may disclose protected health information about you for programs that provide benefits for work-related injuries or illnesses. Communicable Diseases: We may disclose protected health information to notify a person who may have been exposed to a disease or may be at risk of contracting or spreading a disease or condition.

Health Oversight Activities: We may disclose protected health information to federal or state agencies that oversee our activities. Law Enforcement: We may disclose protected health information as required by law or in response to a valid judge-ordered subpoena. For example, in cases of victims of abuse or domestic violence; to identify or locate a suspect, fugitive, material witness, or missing person; related to judicial or administrative proceedings; or related to other law enforcement purposes. Military and Veterans: If you are a member of the armed forces, we may disclose protected health information about you as required by military command authorities.

Lawsuits and Disputes: We may disclose protected health information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful processes. Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose protected health information about you to the correctional institution or law enforcement official. An inmate does not have the right to the Notice of Privacy Practices.

Abuse or Neglect: We may disclose protected health information to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Fundraising: Unless you notify us you object, we may contact you as part of a fundraising effort for our practice. You may opt out of receiving fundraising materials by notifying the practice's compliance department at any time at the telephone number or the address at the end of this document. This will also be documented and described in any fundraising material you receive. Coroners, Medical Examiners, and Funeral Directors: We may disclose protected health information to a coroner or medical examiner. This may be necessary to identify a deceased person or determine the cause of death. We may also disclose protected health information about patients to funeral directors as necessary to carry out their duties.

Public Health Risks: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for purposes such as controlling disease, injury, or disability.

Serious Threats: As permitted by applicable law and standards of ethical conduct, we may use and disclose protected health information if we, in good faith, believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person the public.

Food and Drug Administration (FDA): As required by law, we may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post-marketing surveillance information to enable product recalls, and repairs or replacement.

Research (inpatient): We may disclose information to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved their research.

OUR RESPONSIBILITIES

We are required to maintain the privacy of your health information. In addition, we are required to provide you with a notice of our legal duties and privacy practices with respect to the information we collect and maintain about you. We must abide by the terms of this notice. We reserve the right to change our practices and to make the new provisions effective for all the protected health information we maintain. If we make material changes to our information practices, we will send a revised notice to the address you have supplied. Your health information will not be used or disclosed without your written authorization, except as described in this notice and in accordance with the law. The following uses and disclosures will be made only with explicit authorization from you: (i) uses and disclosures of your health information for marketing purposes, including subsidized treatment communications; (ii) disclosures that constitute a sale of your health information; and (iii) other uses and disclosures not described in the notice. Except as noted above, you may revoke your authorization in writing at any time.

FOR MORE INFORMATION OR TO REPORT A PROBLEM

If you have questions about this notice or would like additional information, you may contact our Compliance Department at the telephone or email address below. If you believe that your privacy rights have been violated, you have the right to file a complaint with the Compliance Department at Flagship Specialty Partners or with the Secretary of the Department of Health and Human Services. The complaint must be in writing, describe the acts or omissions that you believe violate your privacy rights, and be filed within 180 days of when you knew or should have known that the act or omission occurred. We will take no retaliatory action against you if you make such complaints. The contact information for both is included below.

NOTICE OF PRIVACY PRACTICES AVAILABILITY

This notice will be prominently posted in the office where registration occurs. You will be offered a hard copy at the time we first deliver services to you. Thereafter, you may obtain a copy upon request.

 

Thank you for choosing Carolinas Center for Oral & Facial Surgery for your oral surgery needs. Please remember that your insurance policy is a contract between you and your insurance carrier. We will, as a courtesy, bill your insurance and help you receive the maximum allowable benefit under your policy. Some procedures may be covered under your major medical insurance. Some procedures are covered only under your dental policy.

It is your responsibility to provide all necessary insurance eligibility, identification, and referral information and to notify our office of any information changes when they occur. Failure to provide all required information may necessitate patient payment for all charges.

When insurance is involved, we are contractually obligated to collect co-payments, co-insurance, and deductibles, as outlined by your insurance carrier.

If you incur a credit balance from a claim, that credit balance will be applied to any outstanding balance on your account before a refund is issued.

You will be responsible for any services not covered by your plan.

Financial arrangements for future treatment will be discussed at the time of your consultation. For most scheduled procedures your estimated co-pay/co-insurance will be required prior to treatment. If your procedure is not covered by your plan, the balance is due in full prior to treatment.

At your request, we can file an insurance pre-determination. Pre-determinations are only estimates and do not always reflect exact reimbursement.

Some insurance companies, because we are not in their network, will reimburse you directly. Because of this, we may require payment in full for all services.

*Our Practice is OPTED OUT of MEDICARE. Please reference the Medicare Private Contract for more details.

You will receive monthly statements as a reminder to follow up with your insurance company. Please contact your insurance company 30 days after services are rendered to be sure your claim is being processed. Insurance reimbursement is ultimately the responsibility of the patient.

In the event of an overpayment, a refund will be promptly issued to the person listed as the guarantor on the account

By signing below, I acknowledge I have read and understand the CCOFS financial policy. I accept full financial responsibility for this account.