NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DlSCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The Health Insurance Portability & Accountability Act of i996 (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 you're your health information is used. HIPAA provides penalties for covered entities 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 record 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 health care providers. An example of this would include teeth cleaning services.
  • Payment 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 appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest 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 requests to receive confidential communications of protected health information from us by altenative means or at alternative locations.
  • The right to inspect and copy your protected health information.
  • The right to amend your protected health information.
  • The right to receive an accounting of disclosures of protected health information.
  • The right to obtain and we have the obligation to provide to you a paper copy of this notice from us at your first service delivery date.
  • The right to provide and we are obligated to receive a written acknowledgement that you have received a copy of our Notice of Privacy Practices.
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We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

This notice is effective as of June I5, 2003 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 Practices 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 protections have been violated. You have the right to file a formal written complaint with us at the address below, 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 from more information:
Or to file a complaint:

Privacy Officer
Bayou Orthodontics
603 Rue de Lion
New Iberia, LA 70563
(337)367-1271

For more information about HIPAA

The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, DC 20201
(201)619-0257
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:

I acknowledge that I have received 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 anytime 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.

Patient Name:
Relationship to Patient
Signature
Date:

PATIENT INFORMATION FORM

Patient First Name:
DOB:
Sex:
Address:
City
State
Zip
Cell Number:

Needed for appointment reminder text messages

Home Number:
Work Number:
Patient Email:
Do you Attend School?
If so, where?
Responsible Party Information
Patient First Name:
DOB:
Sex:
Relationship to patient:
Address:
City
State
Zip
Cell Number:
Home Number:
Work Number:
Email:
Insurance Information
Policy Holder:
DOB:
Insurance Name:
Social Security:
Subscriber ID:
Employer:
Group Number:
How did you here about us? Please circle one
Others
Emergency Contact Information:
Name:
Phone Number:
Relationship to patient:
Signature of parent/guardian
Date
I understand my signature gives permission to obtain credit bureau reports.
***Please make sure we have your email and cell number on file for Appointment Reminders***

BAYOU BRACES
Photographic / Social Media Consent Form

INFORMATION

I hereby consent to the collection and use of my personal images by taken by Bayou Braces.

I acknowledge these may be used on the Bayou Braces website and Facebook pages, in newsletters and publications as well as distributed to members.

I further acknowledge that my image may be used by the Bayou Braces Committee and media to promote Bayou Braces and events in the future.

I understand that personal information, such as names, may be used in any publications related to Bayou Braces.

I also understand that my consent can be withdrawn at any time in writing to: Bayou Braces
603 Rue de Lion
New Iberia, LA 70563

CONSENT FORM

Consent to the use of photographs or video footage for use on Bayou Braces website for any present or future events.

Initials

Consent to the use of Facebook has a form of communication for daily operations i.e. financials, checking in and out, emergencies and scheduling.

Initials

I further understand that this consent may be withdrawn by me at any time, upon written notice.

  • I give this consent voluntarily

Patient name/Parent giving consent

Signature
Date
  • I decline consent.

Patient name/Parent giving consent

Signature
Date

Potential Risks and Limitations of Orthodontic Treatment

As a rule, excellent orthodontic results can be achieved with informed and cooperative patients. Thus, following information is routinely supplied to anyone considering orthodontic treatment in our office. While recognizing the benefits of a pleasing smile and healthy teeth, you should also be aware that orthodontic treatment, like any treatment of the body, has some inherent risks and limitations. These are seldom enough to contraindicate treatment but should be considered in making the decision to wear orthodontic appliances. As always, we are here to answer your questions.
Decalcification (permanent markings) decay, or gum disease can occur if patients do not brush their teeth properly and thoroughly during the treatment period. Excellent oral hygiene and plaque removal is a must. Sugars and between meal snacks should be eliminated. Preventive visits with your dentist should be made at least semi-annually.
Periodontal Problem (gum inflammation, bleeding, and periodontal disease) can be prevented by proper and regular flossing and brushing. Periodontal disease can be caused by accumulation of plaque and debris around the teeth and gums, but there are several unknown causes that can be lead to progressive loss of supporting bone and recession of the gums. Should the condition become uncontrollable, orthodontic treatment may have to be discontinued short of completion. This would be rare, usually in adults with a preexisting periodontal problem.
Impacted teeth (teeth unable to erupt normally) In attempting to move impacted teeth, especially cuspids, various problems are sometimes encountered which may lead to loss of the tooth or to periodontal problems. The length of time required to move the tooth can vary considerable. Occasionally, twelve-year molars may be trapped under crowns of six-year molars; consequently the removal of third year molars may prove necessary.
Teeth have a tendency to rebound to their original position after orthodontic treatment. This is called relapse. Very severe problems have a higher tendency to relapse and the most common area for relapse is the lower front teeth. After band removal, a positioner or retainers are placed to minimize relapse. Full cooperation in wearing these appliances is vital. We will make our correction to the highest standards and in many cases overcorrect in order to accommodate the rebound tendencies. If retention is discontinued, some relapse is still possible.
Headgear instructions must be followed carefully. A headgear that is pulled outward while the elastic force is attached can snap back and poke into the face or eyes. Be sure to release the elastic force before removing the headgear from the teeth.
A nonvital or dead tooth is a possibility. A tooth that has been traumatized from a deep filling or even a minor blow can die over a long period of time with or without orthodontic treatment: An undetected nonvital tooth may flare up during orthodontic movement, requiring endodontic (root canal) treatment to maintain it.
Unusual Occurrence- Swallowing an appliance, chipping a tooth, and dislodging a restoration; an ankylosed tooth, an abscess or cyst may occur, but these are rare.
In some cases, the root ends of the teeth are shortened during treatment. This is called root resorption. Under healthy circumstances the shortened root s are no disadvantage. However, in the event of gum disease in later life the root resorption could reduce the longevity of affected teeth. It should be noted that not all root resorption arises from orthodontic treatment. Trauma cuts, impaction, endocrine disorder, or idiopathic reasons can also cause root resorption.
There is also a risk that problems may occur in the temporomandibular joints (TMJ). Although this is rare, it is a possibility. Tooth alignment or bite correction can improve tooth-related causes of TMJ pain but not in all cases. Tension appears to play a role in the frequency and severity of joint pains. Poor cooperation can create or aggravate systems.
The total time for treatment can be delayed beyond our estimate. Lack of facial growth, poor elastic or appliance wear, poor cooperation, broken appliances and missed appointments are all important factors which could lengthen treatment time and affect the quality of the result.
In the event of extended treatment due to non-cooperation, cancellations and no-show appointments there will be an additional charge. Charges for these activities will start after the second occurrence and will be based on the procedure and time taken.
Equilibration is the process of recontouring old fillings and other dental restorations after orthodontic treatment. It is occasionally necessary to assist in the final stability of your results. Your family dentist most often performs it, but it can be done by this office but is not included in your orthodontic fee.
In the event treatment is terminated, the amount of treatment rendered will be determined and depending on your individual case, a refund to you or final payment to us will be made based on the following formula:
25%--Earned at the time of banding
100%--Earned by the tenth month of treatment
I grant permission to use my clinical photographs in scientific journals, magazines or lectures. I have read and understand the above and consent to treatment.
Signature
Date
Signature
Date

OFFICE POLICY

1. When agreeing to the financial agreement (contract), please note that your monthly payment is due on the First or the Fifteenth of each month. Monthly payments with office payment plan will be made by automatic draft only. We have this program to make payments as easy as possible and eliminate any risk of late charges.
2. If payment has not been received in our office ten days after the due date and you are not enrolled in our late fee protection plan, or the draft to your account under that plan was declined, a non-refundable $35.00 late fee will be assessed on each past due payment. Our collections department will be contacting you to arrange payment of the past due amount and the late fee.
3. Late charges are applied to each outstanding payment.
4. If your account is 60 days past due, a dismissal letter will be sent via certified mail. This will terminate our responsibility to the patient. Further orthodontic treatment will have to be rendered by another orthodontist. However, if the patient finds alternate financing and pays the entire unpaid balance, as well as, outstanding late fees and charges, active treatment can be reinstated. If the patient prefers we can remove the braces with a fee. Fee will be determined by the office.
5. Our high tech treatment plans allow more time between appointments and reduces school and work loss. A monthly payment plan is a simple, convenient way to spread out the cost of orthodontic treatment; therefore it is still due each month even if there is no appointment during the month.
6. We reserve the right to extend the option to continue payments in the event treatment completes prior to the estimated completion date and/or contract agreement. In the event that the account has necessitated collection activity for delinquent payments, payment in full is required at the time appointments are established for the debanding sequence.
7. Any fees incurred in collecting a delinquent account will be charged to the responsible party for the account.
8. I understand that I am responsible for all fees at time services are rendered, regardless of insurance, including any legal court costs or agency fees incurred in the collection of this account.
9. There will be a $50.00 NSF charge for any checks or auto debits returned.
10. A minimum charge of $25.00 will be applied for any additional filing of insurance or special request forms and/or letters produced by our office.
11. 50% of the down payment will be refunded if the patient decides not to begin treatment after a contract has been signed for administrative fees.

Treatment Cooperation Policy

1. Successful treatment is dependent on the following:
(a) Patient cooperation with headgear, elastic wear and wear
(b) Proper oral hygiene
(c) Care of appliances; broken, lost or distorted appliances add to treatment time
(d) Keeping appointments as schedule (missed or changed appointments interrupt treatment progress)
(e) Eliminating foods and eating habits that break or distort the appliance
(f) Reporting broken or lost appliances promptly
Our services may be discontinued for lack of cooperation.

Appointment Policy

1.Appointments are normally scheduled at one-to-twelve week intervals. These appointments are reserved for our patients so that the best, most efficient orthodontic therapy can be provided. Therefore, some appointments must be during school hours. It is the patient’s responsibility to schedule his/her own appointments on a timely basis. These can be scheduled when leaving after each visit, and are therefore scheduled weeks in advance. One working day in advance cancellation notice is required to cancel an appointment. If an appointment during our “prime” time (7:30am-9:00am and 2:30pm-4:00pm) is cancelled less than one working day before the appointment you will not be allowed to reschedule during another “prime” time slot. If an appointment is missed, it is the patient’s responsibility to contact our office immediately to set up a new appointment.
Reappointment of the original date will reduce the selection of a convenient time. Missed or changed appointments must be rescheduled within one to two weeks of original appointment.

INSURANCE POLICY

1. Our office will assist you with insurance coverage by submitting the initial claim forms and with proper verification; we will accept direct assignment on full orthodontic treatment to make financing easier. An insurance account will be established and the amount of insurance benefits will be transferred from the patient account to the insurance account.
2. Our office will then be responsible for the periodic filing of insurance claims and the follow-up on payments. We are not responsible for disputing claims.
3. If for any reason during active treatment the insurance benefits decrease, change, or are terminated, the unpaid balance will be transferred back into the patient’s account and will be the responsibility of the patient
4. It is the patient’s responsibility to inform us of any change in coverage or company. We may need to ask the patient’s help in filling out the forms or making calls to the insurance company.
5. We reserve the right to refuse to process or accept insurance benefits at any time.
6. There will be a one-time fee for our office to process insurance paper work when we have not accepted assignment of the benefits.

Extra Charges Policy

1. Charges will be made for each missed or changed (in less than 48 hours) appointment longer than 10 minutes and/or in excess of 2 occurrences. Charges will be assessed by length of procedure and to be paid before next appointment.
2. Charges for breakages after 2 during active treatment are payable upon repair. Charges will be assessed by length of procedure to repair and to be paid at the appointment. For all replacement brackets there will be additional fees assessed per bracket.
3. If opted in for the Lifetime Retainer plan the following policy will apply *Only a trutain (clear/plastic) will be given in place of the lost or broken removable retainer with a fee of only $25 for each trutain.
*If the initial contract fee was not paid out, the lifetime retainer policy will be null and voided.

Emergency Policy

1. Emergency appointments after school hours will consist of making patients comfortable. To service you with the best possible care, and ensure completion of a repair being done in one visit, repairs will be scheduled during school hours.
2. One of our assistants will be on call 24 hours a day you may call us at 337-577-8869. Many emergencies can be managed with a phone call; however we will be available to come into the office on weekends and weeknights to make patients comfortable. Repairs cannot be done at these hours.

Payment in full at Debond

1.The balance of your account is due before the braces are scheduled to be removed.

Dental Care Policy

1.General dental care and check-ups are the responsibility of the patient and your regular family dentist. We recommend that you see your family dentist at least every six months during active orthodontic therapy. If you have changed dentist or there has been a change in medical history it is the patient’s responsibility to notify our office as soon as possible.
These policies are subject to change at any time without written notice to current patients.
I have read the above policies and agree to abide by them.
Signature of Responsible Party
Date
Signature of Witness
Date