Bundle : Consent for Treatment, Financial Agreement and Notice of Privacy Practices

I understand that I have the right to accept or reject dental treatment recommended by my dentist.  Prior to consenting to treatment, I will read all the information provided below and consider the benefits, risks, alternative treatments, and option of no treatment.

Exams: I understand that to be properly evaluated and provided current diagnoses, I must consent to receiving a thorough examination by a dentist. This may require study models and/or photographs in addition to clinical examination by the dental provider. I understand that no additional treatment shall be provided should I refuse to receive a dental examination.

X-Rays (Radiographs): I understand that in order to have complete information to make an accurate diagnosis, the dental provider will require radiographs to be taken at dental visits. I understand that Michael D. Vaughan, D.D.S. practices according to the ALARA or “as low as reasonably achievable” principle and only takes x-rays when needed. In addition, Michael D Vaughan, D.D.S. utilizes advanced technology of phosphor plates and digital x-rays, which require significantly less radiation exposure than traditional radiographs. While radiographs may be safely taken if I am pregnant, I will notify staff if I elect to delay imaging until the next appointment.

• Benefits: more complete diagnosis of caries in between teeth, bone loss indicative of potential periodontal disease, and of the nerve and pulp tissue by viewing the roots of the teeth
• Risks: x-ray exposure to radiation (usually less than daily amount of background radiation)

Local Anesthetic: I understand local anesthetic may be required to eliminate discomfort while receiving treatment and it may be administered by a doctor or registered dental hygienist. I have notified the providers in my intake form of any prior diagnosis of methemoglobinemia as well as any known ester (topical anesthetic, benzocaine, oragel), amide (rare) or sulfites (preservatives – methylparaben or metabisulfite) allergies and adverse reactions to anesthetics.

• Non-injectable anesthetic provided in the office is either 20% benzocaine (topical) or Oraqix, 50% lidocaine / 50% prilocaine (intrasulcular).
• Injectable anesthetic (usually lidocaine or articaine) provided in the office is typically mixed with epinephrine, which may cause sweating, shakiness, quickened heartbeat, dizziness, and/or anxiety.
• Benefits: localized anesthesia from treatment being performed, leading to safer care by the provider and comfort for the patient.
• Complications: numbness leading to accidental biting of cheek, lip, tongue resulting in swelling or discomfort, swelling, bleeding, infection, or discomfort at the site of injection; prolonged sense of numbness or lingering tingling sensation (most often temporary); jaw or muscle cramps/spasms; jaw joint discomfort radiating to head, neck, or ears, allergic reaction.

Cleanings: I understand that the type of cleaning recommended will be determined by the examination performed, including periodontal charting and x-rays. Depending on the level of cleanliness, gingival inflammation, and/or bone loss, I may require a prophylaxis, full mouth debridement, and/or scaling and root planing. I authorize the use of floss, hand instruments, ultrasonic scalers, and polishing tools to remove plaque, tartar, and stains. I understand that disease intervention will require work on my part to foster healthy habits such as regular brushing, flossing, and cessation of tobacco use. I understand that my physiologic makeup is different from everyone else, and it is may be impossible to determine the results of healing. If I require antibiotics dose prior to cleaning, I will provide the necessary documentation from my primary care physician or request the medication from my physician.

• Prophylaxis: a preventive procedure that removes the bacterial biofilm and biotoxins caused by food (plaque and calculus)
• Full mouth debridement: is the removal of plaque and calculus that interferes with the dentist’s ability to perform an evaluation. This may need to be completed in conjunction with a prophylaxis or SRP
• Scaling/root planing (SRP): a “deep cleaning” may require local anesthetic to clean under the gums and along root surfaces. I understand that sensitivity is normal for a few weeks and gum recession is a part of healing. Often times, SRP treatment requires more frequent visits, known as "periodontal maintenance" to prevent further progression of periodontal disease.
• Benefits: removal of plaque, tartar, staining; reducing inflammation; reducing periodontal pocketing; preventing further bone loss that can lead to tooth loss; mitigating systemic effects of chronic diseases
• Risks: soreness, bleeding, temporary sensitivity, recession of gums, stretching of lips, corners of mouth
• If an SRP is recommended, and I refuse treatment, I will sign a Treatment Refusal form releasing Michael D. Vaughan, D.D.S. of all liability associated with my untreated condition.

Restorative (Fillings, Crowns, Bridges): I understand that if decay is detected either clinically or radiographically, I will require a restoration in one of the following forms: filling, crown, or bridge.

• Fillings: I consent to restoration of my cavity with a filling. I understand amalgam (silver) fillings are not placed in this office and that composite (white) fillings may be tough to match the exact tooth color on stained teeth. I understand that increased sensitivity may be normal for 4-6 weeks and that I need to be gentle when chewing on teeth with fillings. I understand that if the decay is extensive, a crown or root canal may be indicated instead of a filling.
• Crowns (caps): I understand that a crown may be necessary if I have inadequate sound tooth structure to retain a resin white filling and full coverage requires my tooth to be shaved down. I understand that receiving a crown takes multiple visits and that I will receive a temporary for a few weeks while the crown is being fabricated in a laboratory. I understand that my temporary may come off easily and that I must be careful to ensure it is kept on until the permanent crown is placed. Should my temporary come off, I will notify Michael D Vaughan, D.D.S. and return to have it replaced. I understand that it is my responsibility to return within 3 weeks for permanent cementation and that delays may cause tooth movement or additional decay, which may necessitate a remake of the crown, and I will assume all financial responsibility associated with remake due to delayed cementation. I will be shown the final restoration and given the opportunity to approve or deny based on size, shape, fit, and color prior to cementation. I understand that final cementation is permanent, and that changes beyond that may be at my expense.
• Fixed partial denture (FPD): A “bridge” may be placed to fill any gaps between stable teeth. I understand that in order to qualify for a bridge, my teeth and gums must be in sound periodontal condition and cavity-free. I understand that receiving a bridge requires the adjacent teeth to be shaved down permanently and that the alternative procedure would be implant placement or leaving the space empty. I also understand that leaving an open space will ultimately result in movement of adjacent teeth into the empty space, which could adversely affect my periodontal health.
• Desensitizer (glutaraldehyde): I understand that to provide the best quality of care to patients, Michael D. Vaughan, D.D.S. uses a desensitizing agent to be used under all fillings and crowns. I authorize a non-staining desensitizing agent to be used to avoid sensitivity, but understand that in rare cases, patients have mild allergic reactions to the material (swelling, discomfort). I will notify Michael D. Vaughan, D.D.S. should I have any of these symptoms.
• Alternatives: no treatment or SDF (to buy time for definitive treatment). Please note that the treatment plans may change if an extensive period of time elapses after original diagnosis.

Silver Diamine Fluoride (SDF): SDF has recently been FDA approved to treat teeth for hypersensitivity. It has been shown to arrest decay, and multiple treatments can reduce discomfort while prolonging the need for more invasive procedures (root canal or extractions). I understand that placement of silver diamine fluoride does not restore tooth form lost to decay and cavitated lesions will still need to be restored for optimal function.

• Benefits: reduce pain/sensitivity, arrests decay, can be used to “buy time” for necessary treatment
• Risks: esthetic concerns, stains decay black (tooth turns dark), possible temporary discoloration of gums and tissues
• Contraindications: allergy to silver, localized aphthous ulcers

Root canal therapy (RCT): If a tooth is determined to be restorable and decay has extended past the hard tooth surfaces into the pulp tissue where the nerve resides, RCT will be necessary to save the tooth. I understand the alternative to RCT is to have the tooth removed and by not receiving any definitive treatment, I may be putting myself at risk for further infection. I understand that definitive treatment for "irreversible pulpitis" or nerve damage that may occur within a tooth that has a filling is to receive an RCT. If I agree to receive an RCT, I will be provided an additional consent listing out all risks and benefits and will get a chance to ask questions prior to treatment. I understand that for difficult cases, I may be provided a referral to have an outside specialist treat the tooth in question.

Extractions (EXT): If a tooth is mobile due to significant bone loss or non-restorable due to decay, it may require either a simple or surgical extraction. I understand that I may elect to extract a tooth in lieu of definitive treatment options that can save the tooth (root canal, crown, filling).  I may elect to do nothing or receive silver diamine fluoride to delay treatment until I have decided on a permanent solution.  If I agree to receive an EXT, I will be provided with an additional consent listing out all risks and benefits and will get a chance to ask questions prior to treatment.  I will discuss options for replacing the tooth with the doctor prior to extraction.

Complete or Partial Dentures (Removable Prosthetics): Missing teeth may be replaced with a partial or complete removable denture and I understand that it can often take months to receive dentures due to necessary laboratory work. I understand that if I do not have adequate bone structure, I may require denture adhesive to retain dentures for ideal form and function.

• Complete dentures (CD): I understand that complete dentures may often require relines or adjustments after initial fabrication. Immediate dentures can be delivered upon extraction of remaining teeth, but will result in additional inflammation and discomfort. I understand that I cannot remove immediate dentures for the first 24 hours after extractions. I will notify Michael D. Vaughan, D.D.S. of any sore spots and return with the dentures for adjustment visits as needed.
• Removable partial denture (RPD, cast metal framework or transitional): I understand that the type of partial recommended is dependent upon my current periodontal condition. If I plan to proceed with a cast metal partial, I understand that caries control is prioritized and I authorize Michael D. Vaughan, D.D.S. to make any small grooves or adjustments to my existing dentition to ensure proper fit of partial denture. I understand that partials can also cause periodontally involved teeth to become more unstable.
• Benefits: regain form, some function, and esthetics
• Risks: suboptimal function, sore spots, altered speech, difficulty eating, immediate dentures (upon ext) may require additional adjustments and relines, are more painful, and often not included in the denture fee
• Alternative treatment: For some patients, implants or bridges may be viable options. Otherwise, I understand I can elect to receive no treatment and remain partially or completely edentulous, where lack of adequate support can cause additional shifting of teeth and progression of periodontal disease.

Mild or Moderate Conscious Sedation: I understand that if I am slightly nervous, I can elect to use nitrous oxide gas for a nominal charge. I understand that I am more anxious, I may elect to receive mild or moderate sedation in the form of oral sedation, IM sedation, or IV sedation and will need to fill out an additional consent form as well as provide all necessary medication information prior to the appointment. I understand that I will require someone to accompany me during oral, IM, or IV sedation, as I will be unable to drive after my procedure. I will ask all the necessary questions ahead of time to arrive to a conclusion prior to procedure should any changes be made during the sedation.

• Nitrous Oxide (N₂O): A colorless, slightly sweet gas used for mild anxiety. I understand that when inhaled, it can induce feelings of euphoria and mild sedation, and that I can continue to swallow, talk, cough, through the procedure. I understand the effects are mild and can be eliminated from the body when no longer administered.
• Benefits: safe, inexpensive, quick onset, can be titrated, can return to work and/or drive
• Risks: doesn’t work for everyone, can cause increased anxiety, hypoxia, overdose, dizziness, nausea
• Contraindications: pregnancy, mouth breathing, COPD, untreated B12 deficiency

Changes in Treatment Plan: I understand that during treatment, it may be necessary to change or add procedures because of conditions discovered while working on teeth. The most common would be root canal therapy or extraction instead of a routine restorative procedure. I give permission to the dentist to make any and all changes or additions necessary to adequately diagnose and safely treat, including during sedation if I am unable to give informed consent at the time.

I understand that medications or prescription medications given in or by the office are common. I have provided, to the best of my ability, accurate information regarding my medical diagnoses, medications, allergic reactions (itching, swelling, breathing difficulty), and adverse reactions (nausea, vomiting, headaches, drowsiness) to allow the dentist to provide me with the safest treatment possible.

With this information, I am providing consent for dental procedures to be performed. I understand I will be provided an additional consent for more complicated procedures and be given the opportunity to ask any questions I may have regarding treatment. Should I choose no treatment, I hereby release Michael D. Vaughan, D.D.S. of all liability associated with consequences resulting from my diagnosis.

This agreement is to inform you of your financial obligation for your dental service. 
 

Our office will accept an assignment of benefits from your insurance company with the provisions listed below.  The following provisions identify our policies governing insurance claims and payment:

1. We will use our best efforts to complete insurance information forms and submit a claim on your behalf. Our office will not enter into a dispute with your insurance company over any claim. We will provide necessary documentation your insurance company requests. We will cooperate fully with the regulations and requests of your insurance company.  It is ultimately your responsibility to resolve any type of dispute over payments made or not made by your insurance company.
   
2. We require you to pay the estimated co-payment, which is the amount not covered by your insurance company, at the time we provide service to you. The co-payment is only an estimate of charges and may be found to be insufficient after review by your insurance company. Our office accepts cash, MasterCard, Visa, Discover and American Express.  In addition, we offer outside financing through Care Credit.
   
3. Insurance payments ordinarily are received within 30-60 days from the time of billing. If your insurance company has not made payment to our office within 60 days from the time of billing, we will ask you to pay the remaining balance at that time.  You will be responsible for seeking reimbursement from your insurance company.
   
4. Our office does not guarantee that your insurance company will pay for treatment you receive from our practice. We perform routine insurance billing procedures upon verification of coverage.  However, if your claim is denied, you will be responsible for paying the full amount at that time.
   
5. If you are unable to keep your account current, we may be unable to provide additional dental services except for where services are prepaid.
   
6. In case of default, you agree to pay collection costs and reasonable attorney fees.
   

Please do not hesitate to ask if you have any questions regarding this financial agreement. We are committed to providing you with the most positive experience in dental care.

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

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 notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect September 23, 2013, 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 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 any significant change in our privacy practices we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for your treatment, payment, and healthcare operations. For example:

• Treatment - We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
• Payment - We may use and disclose your health information to obtain payment for services we provide you.
• Healthcare Operations - We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities.
• Your Authorization - In addition to our use of your health information for treatment, payment, or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.
• To Your Family and Friends - We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
• Persons Involved In Care - We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) family members, 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 practices 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.
• Marketing Health-Related Services - We will not use your health information for marketing communications without your written authorization.
• Required by Law - We may use or disclose your health information when we are required to do so by law.
• Abuse or Neglect - We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence, or the possible victim of other crimes. We may disclose your Health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
• National Security - 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.
• Appointment Reminders- We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, emails, text messages, or letters).

PATIENT RIGHTS

• Access - You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request, unless we cannot practically do so. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this notice. We will charge a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this notice. If you request copies, we will charge you $0.50 for each page, $10 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.
• Disclosure Accounting - You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, healthcare operations and certain other activities, for the past 6 years. If you request this accounting more than once in a 12 month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
• Restriction - You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by your agreement (except in an emergency).
• Alternative Communication - You have the right to request how we communicate with you about your health information by alternative means, or to alternative locations. You must make your request in writing. Your request must specify the alternative means or locations and provide satisfactory explanation for how payments will be handled under the alternative means or location your request.
• Amendment - You have the right to request we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.
• Electronic Notice - If you receive this notice on our web site, via e-mail, or by other electronic means, you are entitled to receive this Notice in written form as well.

ADDITIONAL IMPORTANT INFORMATION

Health Insurance Portability and Accountability Act or HIPPA does not permit a covered dental practice to allow a business associate access to patient information until the dental practice and the business associate have signed a written agreement containing certain required provisions. This agreement is called a business associate agreement or business associate contract.

Covered dental practices must update their existing business associate agreements, which we have done.

All business associates must comply with the HIPPA security rules. Associates must also comply with HIPPA privacy rules, and report any breach of unsecured, protected medical history to you, and to the Practice. Our business associates must require the same of any subcontractors.

The following use and disclosure requires the patient’s authorization:

• Many uses of psychotherapy notes
• Uses and disclosures of protected health information for marketing The sale of protected health information

The patient has the right to require restrictions on certain use or disclosure of protected health information, including the right to pay out of pocket for treatment and not have the bill for services be submitted to your health plan or insurance company.

You have the right to opt out of receiving fundraising communications.

We follow HIPPA guidelines and industry standards to protect patient health information. If there is ever a breach of your protected health information, you will be notified.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative locations, you may complain to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. You have the right to look at or get copies of your health information, with limited exceptions.

Michael D. Vaughan, D.D.S.

Contact Officer: Jason Taylor / COO

Telephone: 615-915-6106 / Fax: 615-915-6091

E-mail: jason@mdvdds.com

Address: 330 Wallace Road, Suite 106, Nashville TN 37211