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It is my responsibility to inform the dental office of any changes in medical status.", "headingLabel": "Comments"}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "subLabelStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "top", "direction": "vertical"}}, "settings": {"required": false}, "controlType": "longText", "placeholders": {"longTextPlaceholder": "", "subLabelPlaceholder": "Type a sublabel"}, "controlTypeLabel": "Long Text"}, {"qid": 271, "labels": {"headingLabel": "Signature"}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "top", "direction": "vertical"}}, "settings": {"required": true}, "controlType": "signature", "controlTypeLabel": "Signature"}]}, {"page": 7, "questions": [{"qid": 277, "labels": {"headingLabel": "Dental History", "subHeadingLabel": ""}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "left", "direction": "vertical"}, "subHeadingStyle": {}}, "settings": {"required": false}, "controlType": "heading", "placeholders": {"subHeadingPlaceholder": "Type a subheader"}, "controlTypeLabel": "Heading"}, {"qid": 278, "labels": {"prefixLabel": "Prefix", "suffixLabel": "Suffix", "headingLabel": "Patient Name", "lastNameLabel": "Last Name", "firstNameLabel": "First Name", "middleNameLabel": "Middle Name"}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "labelStyle": {}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "top", "direction": "vertical"}, "inputGroupStyle": {}}, "options": {"prefix": false, "suffix": false, "middleName": false}, "settings": {"required": true}, "controlType": "fullName", "placeholders": {"prefixPlaceholder": "", "suffixPlaceholder": "", "lastNamePlaceholder": "", "firstNamePlaceholder": "", "middleNamePlaceholder": ""}, "controlTypeLabel": "Full Name"}, {"qid": 280, "labels": {"subLabel": "", "headingLabel": "What concerns you most about your teeth?"}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "subLabelStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "top", "direction": "vertical"}}, "settings": {"required": false}, "controlType": "longText", "placeholders": {"longTextPlaceholder": "", "subLabelPlaceholder": "Type a sublabel"}, "controlTypeLabel": "Long Text"}, {"qid": 281, "labels": {"content": "

Please check any of the following which apply to you, and add any relevant comments:

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"paddingRight": "0rem", "paddingBottom": "0rem"}, "columnStyle": {"columns": 2}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "top", "direction": "vertical"}, "inputFieldStyle": {}, "radioButtonStyle": {}}, "choices": [{"label": "Yes"}, {"label": "No"}], "settings": {"required": true}, "controlType": "singleChoice", "placeholders": {}, "controlTypeLabel": "Single Choice"}, {"qid": 300, "labels": {"headingLabel": "Signature"}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "top", "direction": "vertical"}}, "settings": {"required": true}, "controlType": "signature", "controlTypeLabel": "Signature"}]}, {"page": 8, "questions": [{"qid": 301, "labels": {"headingLabel": "Stone Oak Aesthetic Dentistry Notice of Privacy Practices", "subHeadingLabel": "THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY."}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "left", "direction": "vertical"}, "subHeadingStyle": {}}, "settings": {"required": false}, "controlType": "heading", "placeholders": {"subHeadingPlaceholder": "Type a subheader"}, "controlTypeLabel": "Heading"}, {"qid": 302, "labels": {"content": "We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 9/1/2013, and will remain in effect until we replace it."}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "left", "direction": "vertical"}}, "settings": {"required": false}, "controlType": "paragraph", "placeholder": "Click to edit this text...", "controlTypeLabel": "Paragraph"}, {"qid": 303, "labels": {"content": "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, and to make new Notice provisions effective for all protected health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new Notice upon request."}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "left", "direction": "vertical"}}, "settings": {"required": false}, "controlType": "paragraph", "placeholder": "Click to edit this text...", "controlTypeLabel": "Paragraph"}, {"qid": 304, "labels": {"content": "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."}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "left", "direction": "vertical"}}, "settings": {"required": false}, "controlType": "paragraph", "placeholder": "Click to edit this text...", "controlTypeLabel": "Paragraph"}, {"qid": 305, "labels": {"content": "

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

"}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "left", "direction": "vertical"}}, "settings": {"required": false}, "controlType": "paragraph", "placeholder": "Click to edit this text...", "controlTypeLabel": "Paragraph"}, {"qid": 306, "labels": {"content": "We may use and disclose your health information for different purposes, including treatment, payment, and health care operations. For each of these categories, we have provided a description and an example. Some information, such as HIV-related information, genetic information, alcohol and/or substance abuse records, and mental health records may be entitled to special confidentiality protections under applicable state or federal law. We will abide by these special protections as they pertain to applicable cases involving these types of records."}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "left", "direction": "vertical"}}, "settings": {"required": false}, "controlType": "paragraph", "placeholder": "Click to edit this text...", "controlTypeLabel": "Paragraph"}, {"qid": 307, "labels": {"content": "Treatment. We may use and disclose your health information for your treatment. For example, we may disclose your health information to a specialist providing treatment to you."}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "left", "direction": "vertical"}}, "settings": {"required": false}, "controlType": "paragraph", "placeholder": "Click to edit this text...", "controlTypeLabel": "Paragraph"}, {"qid": 308, "labels": {"content": "Payment. We may use and disclose your health information to obtain reimbursement for the treatment and services you receive from us or another entity involved with your care. Payment activities include billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your dental health plan containing certain health information."}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "left", "direction": "vertical"}}, "settings": {"required": false}, "controlType": "paragraph", "placeholder": "Click to edit this text...", "controlTypeLabel": "Paragraph"}, {"qid": 309, "labels": {"content": "Healthcare Operations. We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, conducting training programs, and licensing activities."}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "left", "direction": "vertical"}}, "settings": {"required": false}, "controlType": "paragraph", "placeholder": "Click to edit this text...", "controlTypeLabel": "Paragraph"}, {"qid": 310, "labels": {"content": "Individuals Involved in Your Care or Payment for Your Care. We may disclose your health information to your family or friends or any other individual identified by you when they are involved in your care or in the payment for your care. Additionally, we may disclose information about you to a patient representative. If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information."}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "left", "direction": "vertical"}}, "settings": {"required": false}, "controlType": "paragraph", "placeholder": "Click to edit this text...", "controlTypeLabel": "Paragraph"}, {"qid": 311, "labels": {"content": "Disaster Relief. We may use or disclose your health information to assist in disaster relief efforts."}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "left", "direction": "vertical"}}, "settings": {"required": false}, "controlType": "paragraph", "placeholder": "Click to edit this text...", "controlTypeLabel": "Paragraph"}, {"qid": 312, "labels": {"content": "Required by Law. We may use or disclose your health information when we are required to do so by law."}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "left", "direction": "vertical"}}, "settings": {"required": false}, "controlType": "paragraph", "placeholder": "Click to edit this text...", "controlTypeLabel": "Paragraph"}, {"qid": 313, "labels": {"content": "Public Health Activities. We may disclose your health information for public health activities, including disclosures to: Prevent or control disease, injury or disability; Report child abuse or neglect; Report reactions to medications or problems with products or devices; Notify a person of a recall, repair, or replacement of products or devices; Notify a person who may have been exposed to a disease or condition; or Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence."}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "left", "direction": "vertical"}}, "settings": {"required": false}, "controlType": "paragraph", "placeholder": "Click to edit this text...", "controlTypeLabel": "Paragraph"}, {"qid": 314, "labels": {"content": "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 the protected health information of an inmate or patient."}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "left", "direction": "vertical"}}, "settings": {"required": false}, "controlType": "paragraph", "placeholder": "Click to edit this text...", "controlTypeLabel": "Paragraph"}, {"qid": 315, "labels": {"content": "Secretary of HHS. We will disclose your health information to the Secretary of the U.S. Department of Health and Human Services when required to investigate or determine compliance with HIPAA."}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "left", "direction": "vertical"}}, "settings": {"required": false}, "controlType": "paragraph", "placeholder": "Click to edit this text...", "controlTypeLabel": "Paragraph"}, {"qid": 316, "labels": {"content": "Worker's Compensation. We may disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to worker's compensation or other similar programs established by law."}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "left", "direction": "vertical"}}, "settings": {"required": false}, "controlType": "paragraph", "placeholder": "Click to edit this text...", "controlTypeLabel": "Paragraph"}, {"qid": 317, "labels": {"content": "Law Enforcement. We may disclose your PHI for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order."}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "left", "direction": "vertical"}}, "settings": {"required": false}, "controlType": "paragraph", "placeholder": "Click to edit this text...", "controlTypeLabel": "Paragraph"}, {"qid": 318, "labels": {"content": "Health Oversight Activities. We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws."}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "left", "direction": "vertical"}}, "settings": {"required": false}, "controlType": "paragraph", "placeholder": "Click to edit this text...", "controlTypeLabel": "Paragraph"}, {"qid": 319, "labels": {"content": "Judicial and Administrative Proceedings. If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone eke involved in the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about the request or to obtain an order protecting the information requested."}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "left", "direction": "vertical"}}, "settings": {"required": false}, "controlType": "paragraph", "placeholder": "Click to edit this text...", "controlTypeLabel": "Paragraph"}, {"qid": 320, "labels": {"content": "Research. We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information."}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "left", "direction": "vertical"}}, "settings": {"required": false}, "controlType": "paragraph", "placeholder": "Click to edit this text...", "controlTypeLabel": "Paragraph"}, {"qid": 321, "labels": {"content": "Coroners, Medical Examiners, and Funeral Directors. We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties."}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "left", "direction": "vertical"}}, "settings": {"required": false}, "controlType": "paragraph", "placeholder": "Click to edit this text...", "controlTypeLabel": "Paragraph"}, {"qid": 322, "labels": {"content": "Fundraising. We may contact you to provide you with information about our sponsored activities, including fundraising programs, as permitted by applicable law. If you do not wish to receive such information from us, you may opt out of receiving the communications."}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "left", "direction": "vertical"}}, "settings": {"required": false}, "controlType": "paragraph", "placeholder": "Click to edit this text...", "controlTypeLabel": "Paragraph"}, {"qid": 323, "labels": {"content": "

Other Uses and Disclosures of PHI.

Your Health Information Rights

Questions and Complaints

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.

Stone Oak Aesthetic Dentistry will not tolerate disrespect, misconduct, inappropriate or threatening behavior towards any member of our team. We reserve the right to terminate any patient from the practice at our discretion in accordance with Texas State Board of Examiners (TSBDE) Rule 108.5.

Our Privacy Official: Bradly T. Beckel Telephone: 210-341-4409

Address: 1202 East Sonterra Blvd.

E-mail: admin@stoneoakaesthetics.com

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

In our office, you have a variety of financial options from which to choose.The office accepts the following forms of payment:

Cash
Personal Checks
Debit Cards
Major Credit Cards
Carecredit

The following payment options are also available to you:

A. In cases requiring laboratory work, it may be possible to pay for treatment with 50% due on the day of initial treatment and the balance paid in one or two subsequent payments.The Office Manager will discuss these payment options with you.

C. Many of our patients request our assistance in the filing of insurance claims. We are pleased to provide this service. However, we are not a preferred provider for any insurance company or a participant in any network. Our office does not accept assignment of insurance benefits. In other words, we do not accept partial payment for treatment and have the insurance reimbursement check sent to our office. The contract is between the patient and the insurance company. For this reason, the insurance company is more responsive to the patient than to the treating dentist. Insurance payments directly to the patient are made much more promptly, generally 2-3 weeks. If the patient makes payment by credit card, the insurance check is commonly received by the patient prior to the credit card billing cycle.

For identification purposes, we will take your photograph for your profile. In some cases, diagnostic photographs and scans are needed as part of your comprehensive exam. We value your privacy and will always ask for your consent before using your photographs for any other purpose, such as social media, websites, printed materials, etc. If you have any questions or concerns, feel free to ask us. Thank you for choosing our team for your dental care.

I authorize Stone Oak Aesthetic Dentistry to discuss information related to my dental care with: