HIPAA Consent Form

Dalseth Family and Cosmetic Dentistry, PA-

We may need to contact you, by written correspondence mailed to your residence, email or by phone, to deal with matters related to your appointments, test results, treatments, referrals, account balance and/or to return your phone call. We will first attempt to contact you at home/cell, however if you are not available and you provide us with your work number, we will attempt to contact you at work. If you are not available, we will leave a message for you to call the office for a specified reason (i.e. discuss test results, account balance) or we will remind you of your appointment time.

In the event you do not pay all of your charges in full at the time of your visit, we will mail a statement to your home. Also, depending upon your situation, we may mail recall cards to your home noting that you need to contact the office to schedule an appointment. We will use the home address you provided us with at the time you registered with the practice.

We may contact your insurance company to determine your coverage, eligibility, unmet deductible and/or your co-insurance and co-pay requirements. If necessary for obtaining payment, we will provide credit bureaus and/or collection agencies with your account information.

When you arrive at our practice for your appointment, we will ask you to check in and note your arrival time. We will do our very best to see you promptly. However, there may be times when your provider is running behind schedule and you will need to wait in the reception area.

You must provide written authorization for the release of information to entities such as a life or disability insurer or for the purpose of transferring your record to another dentist or medical facility. At your request, we will send you the necessary form to complete for this authorization.

You may review and/or obtain a copy of your dental record. You may request, in writing, changes be made to your dental record. We will review your reason(s) for such a request and if we agree, will make the change(s). If we do not agree with your request, you are entitled to have your statement added to the record. Also, you may request information regarding who we have disclosed your medical information to for purposes other than treatment, payment and health care operations. Please provide us with current information regarding your phone numbers (work cell and home), email and home billing address. This will allow us to make the correct contact when trying to reach you. When necessary, these policies will be modified to ensure compliance with practice operations and with State and Federal privacy regulations. If you have any questions or concerns with the policies and/or procedures noted above, please contact our practice at: 14505 Glazier Ave, Apple Valley, MN 55124 or call 952-432-1101 or email at: info@dalsethdental.com to report any and all concerns. We trust that you are comfortable with our sincere efforts to maintain the confidentiality of the information related to your medical care. You may revoke any aspects of this consent at any time by giving us written notice. Finally, if you believe we have not maintained the privacy of your records, you may file a complaint with the Secretary of the US Dept. of Health & Human Services.