Welcome to our Practice

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Name:____________________________________ DOB:____________________

At Chesapeake Periodontics, we make every effort to provide the finest periodontal, implant and oral medicine at a fair and reasonable cost to our patients. Our mission is to make you healthy, attractive and functional. We do not render services on the basis of what insurance will cover.

It is most important to us that every patient is completely informed not only of the treatment to be rendered in our office but also of the financial investment for that treatment. The fee necessary to complete a particular treatment plan is based on an estimate derived from your examination. Should additional unforeseen problems arise as treatment progresses, this estimate may have to be revised. You will be consulted and informed before any unexpected treatment is undertaken.

For our new patients, and those involved in extensive treatment, specific financial arrangements are usually discussed as part of a separate consultation visit. For those patients with limited (1-2 visits) treatment, it will be expected that payment be made in full on the day of service or prior to. Please advise our staff if financial arrangements are necessary. In-office financing is available for up to four months. Long term financing is available to our patients through other lenders. Please ask to speak to our financial coordinator for more information.

If you have dental insurance, we will help you maximize your reimbursement for covered procedures. As a courtesy, we will file your insurance claim up to two times. You will need to provide us with accurate and current insurance information and proof of coverage (insurance ID card or insurance forms) at your initial consultation. While our dental team will be glad to help you with your coverage, it is important that you are familiar with your plan. Please keep in mind you are responsible for your total obligation should your insurance company deny a claim, delay payment for 60 days, or if benefits are less than anticipated. Most insurance companies will respond within six to eight weeks. Please call our office if you have not gotten a response from your insurance company within that time frame. It is a common practice for insurance companies to delay payment. Please do not assume that any correspondence sent to you has also been sent to us. A health insurance company is not in the business to make you healthy, Chesapeake Periodontics is.

Currently, Dr. Gartner and Dr. Duckworth directly participate with Delta Dental PPO, Delta Premier, and all Cigna plans. We will submit to all insurance companies as a courtesy.

For your convenience the following methods of payment are available in our office: cash, personal check, American Express, Visa, Master Card, Discover and Care Credit. Care Credit is a medical credit card, which can be used for extended payment requests. Our staff can assist in processing an application on your behalf.

There will be a $35.00 handling fee, in addition to any bank charges for any returned checks.

If you have any questions regarding your account or our policies, please call us at 410-647-0200.

I have read and understand the financial policies outlined above. I understand that I am fully responsible for all services rendered by Dr. Gartner, Dr. Duckworth and their staff.

Signed____________________________________________________________________ Date_____________________________

For Office Use Only

Copy of signed authorization provided to the individual:

Date: _____________________________________

Initials: __________________________________

Chesapeake Periodontics Financial Policy

Insurance Authorization & Billing Information

Signature on File Form

The following authorizations are included on all dental claims. Because we submit the claims for you, a ‘Signature on

File’ must be kept in your record. Please sign both authorizations.

AUTHORIZATION TO RELEASE INFORMATION: I have been informed of the treatment plan and associated fees. I

agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless prohibited

by law or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such

charges. To the extent permitted by law, I consent to your use and disclosure of my protected health information to carry our

payment activities in connection with this claim.

X ____________________________________________________________________ Date ___________

Signed (patient, parent or legal guardian if minor)

AUTHORIZATION TO PAY BENEFITS TO NAMED DENTIST: I hereby authorize and direct payment of the dental

benefits otherwise payable to me, directly to the below named dentist or dental entity.

X ____________________________________________________________________ Date ___________

Signed (patient, parent or legal guardian if minor)

As an option to facilitate a speedy check out, we can keep your credit card information on file. If you choose this

option please read the following authorization and complete your billing information below.

CONTINUOUS AUTHORIZATION

I authorize Chesapeake Periodontics to keep my signature on file and to charge my credit card account listed below for

treatment performed in this office on any given date of service as well as any balance left after my claims are paid. I

understand that this authorization will remain in effect for a period of 24 months, unless I cancel this authorization in writing.

I also understand that my billing information is kept in the strictness of confidentiality.

We offer limited payment arrangements involving a choice of post – dated checks or the following authorization to

bill your credit card on file.

PAYMENT ARRANGEMENT AUTHORIZATION

I authorize Chesapeake Periodontics to charge my credit card account listed below in accordance with the following

payment arrangement. I understand that this authorization will remain in effect until the arrangement has been satisfied

or my balance is paid in full. I also understand that my billing information is kept in the strictness of confidentiality.

PAYMENT ARRANGEMENT

Name: ___________________________________________________________________ Date _______________

Balance Due: ___________ Payment Amount: ___________ Scheduled Billing Date(s): ______________________

Cardholder Signature:___________________________________________________Exp. date_____________

CREDIT CARD (Circle one) Visa MasterCard

Cardholder Name: ______________________________________________________________________________

Billing Address: _______________________________________________________________________________

Account Number: _______________________________________________________________CV Code _______

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Chesapeake Periodontics

CONSENT FOR USE AND DISCLOSRE OF HEALTH INFORMATION

SECTION A: PATIENT GIVING CONSENT Name: __________________________________________________________________________________________________ Chart ID: ____________________________ SECTION B: TO THE PATIENT-PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY Purpose of Consent: I hereby give my consent for Chesapeake Periodontics to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operation (TPO). (The Chesapeake Periodontics Notice of Privacy Practices provides a more complete description of such disclosures.) I have the right to review the Notice of Privacy Practices prior to signing this consent. Chesapeake Periodontics reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a request to the Privacy Officer or any member of our staff at 900 Ritchie Hwy, Suite 103, Severna Park, MD 21146. With this consent, Chesapeake Periodontics may call my home or other alternative location and leave a message on voicemail or in person in reference to any items that assist this practice in carrying our treatment, payment and healthcare operations, such as appointment reminders, insurance items and any calls pertaining to my clinical care. With this consent, Chesapeake Periodontics may mail to my home or other alternative location any items that assist this practice in carrying out our treatment, payment and healthcare operations, such as appointment reminder cards or patient statements. I have the right to request that Chesapeake Periodontics restrict how it uses or discloses my PHI to carry treatment, payment or healthcare operations. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to Chesapeake Periodontics use and disclosure of my PHI to carry out treatment, payment and healthcare operations. I may revoke my consent in writing except to the extent that the practice has already make disclosures in reliance upon my prior consent. If I do no sign this consent, or later revoke it, Chesapeake Periodontics may decline to provide treatment to me. NOTE: If you would like anyone else (spouse, partner, parent, etc.) to have access to your PHI, please ask us for the appropriate form. Signature: ____________________________________________________________________________________________ Date: __________________________________ If a personal representative on behalf of the patient signs this consent, please complete the following: Print Name:___________________________________________________________________________________________________________________________________ Signature: _____________________________________________________________________________________________________________________________________ Relationship to Patient: ______________________________________________________________________________________________________________________

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT Include completed Consent in the patient’s chart

For Office Use Only

Copy of signed authorization provided to the individual: Date: _____________________________________ Initials: __________________________________

Chesapeake Periodontics

Acknowledgement of Receipt of Notice of Privacy Practices

* You May Refuse to Sign This Acknowledgement *

I have received a copy of this office’s Notice of Privacy Practices.

Print Name: __________________________________________________________________________________________ Signature: ____________________________________________________________________________________________

Date: __________________________________________________________________________________________________

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Individual refused to sign

Communication barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

Other (Please Specify)

_________________________________________________________________________________________________

Effective Date of This Notice 4/15/2003

February 2, 2014

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Chesapeake Periodontics

NOTICE OF PRIVACY PRACTICES Effective date April 15 2003, Revised February 2,2014

As Required by the Privacy Regulations Created as a Result of the Health Insurance

Portability and Accountability Act of 1996 (HIPPA)

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PAITNT

OF THIS PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION

WHO WILL FOLLOW THIS NOTICE:

All employees of Chesapeake Periodontics All Business Associates

PLEASE REVIEW THIS NOTICE CAREFULLY.

THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR COMMITMENT TO YOUR PRIVACY Our practice is dedicated to maintaining the privacy of your Protected Health Information (PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by applicable federal and state law to maintain the privacy of health information that identifies you. We are also required to provide you with this 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. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time. We reserve the right to revise or amend change this Notice of Privacy Practices, provided applicable federal and state law permits such changes, at any time. Any revision or amendment to this Notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. We realize that these laws are complicated, but we are required by law to:

Make sure that Protected Health Information that identifies you is kept private. Give you this Notice of our legal duties and privacy practices with respect to medical

information about you. Follow the terms of the Notice that is currently in effect. In the event your health information is breached, we are required to provide you with notice

of the breach. 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.

Effective Date of This Notice 4/15/2003

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HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU We may use and disclose your health information for different purposes, including treatment, payment and health care operations. 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. Treatment: We may use and disclose your health information to a physician or other healthcare providers providing treatment to you. For example, we might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. The staff that works for our practice, including, but limited to, our doctors and hygienists, may use or disclose your PHI in order to treat you or to assist others in your treatment. Payment: We may use and disclose your health information to obtain payment for treatment and

services you receive from us. 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. Healthcare Operations: We may use and disclose your health information in connection with our business. 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. We may disclose your PHI to other health care providers and entities to assist in their health care operations. 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 is in effect. Unless you give us a written authorization we cannot 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 Your Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, 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. 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. We will also use our professional judgment and our experience with common practice 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. You may restrict sharing your health information with someone who is involved in your care. Disaster Relief: We may use or disclose your health information to assist in disaster relief efforts.

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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 an authorized federal official health information required for lawful intelligence, counterintelligence or other national security activities. Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters). 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 HIPPA.

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 practicably do so. If you request information that we maintain on paper, we may provide photocopies. If you request information that we maintain electronically, you have the right to an electronic copy. (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 you a reasonable cost-based fee for expenses such as cost of supplies and labor for copying, and for postage if you want copies mailed to you. 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 $.70 for each page, $10.00 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.) Accounting of Disclosures: 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, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. 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 PHI for treatment, payment or healthcare operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment of your care, such as family members and friends. In order to request a restriction in our use or disclosure of your PHI, you must make you request in writing to the Privacy Official. Your written request describe in a clear and concise fashion:

What information you want to limit Whether you want to limit our use, disclosure or both To whom you want the limits to apply.

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We are not required to agree to your request unless your request pertains to not disclosing health information to a health plan for payment or operations related to services you, or a person on your behalf, paid in full from your pocket. If we do agree with your request, we are bound by our agreement, except when otherwise required by law, in emergencies or when the information is necessary to treat you. Alternative Communication: You have the right to request that 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 location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request. We will accommodate all reasonable requests. You are not required to provide us with an explanation as to the reason for your request. If you would like to receive copies of your information after treatment, you will specify the method and location that information should be sent to you. Amendment: You have the right to request that we amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. Your request must be made in writing. You must provide us with a reason that supports your request for amendment. We may deny your request under certain circumstances. If we agree to your request, we will amend your record(s) and notify you of such. If we deny your request for an amendment, we will provide you with a written explanation of why we denied it and explain your rights. Right to Notification of a Breach: You will receive notifications of breaches of your unsecured protected health information as required by law. Right to a Paper Copy of This Notice: You are entitled to receive a paper copy of our Notice of Privacy Practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, please contact our Privacy Officer or any member of our staff. Right to File a Complaint: 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 you may complain to us or with the Secretary of the Department of Health and Human Services. To file an complaint with our practice, please contact the Privacy Officer. All complaints must be in writing. 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 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. Right to Provide an Authorization for Other Uses and Disclosures: Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Your authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note, we are required to retain records for your care. Contact Officer: Amanda Toomey Telephone: 410-647-0200 Fax: 410-315-8456 E-mail: chesapeakeperio@gmail.com Address: 900 Ritchie Highway, Suite 103, Severna Park, Maryland 21146 If you want more information about our privacy practices or have questions or concerns, please contact us.