NOTICE OF PRIVACY POLICY FOR PINOLE FAMILY DENTAL
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.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that health providers keep your medical and dental information private. The HIPAA Privacy Rule states that health providers must also post in a clear and prominent location, and provide patients with, a written Notice of Privacy Policy.
The privacy practices described are currently in effect. We reserve the right to change our privacy practices, and the terms of this Notice, at any time, provided such changes are permitted by law. If changes are made, a new Notice of Privacy Policy will be displayed in our office and provided to patients. You may request a copy of our Notice at any time. Additional information may be obtained from the HIPAA Coordinator listed in our written HIPAA Plan.
USES AND DISCLOSURES OF HEALTH INFORMATION
The following describes how information about you may be used in this dental office:
- Treatment Services: We may use or disclose your health information to all of our staff members, other dentists, your physicians, and or other health care providers taking care of you.
- Payment and Health Care Operations: We may use and disclose your health information to obtain payment for services we provide to you, to participate in quality assurance, disease management, training, licensing, and certification programs. Upon your written request, we will not disclose to your health insurer any services paid by you out of pocket.
- Marketing/Fundraising: We will not use your health information for marketing or fundraising purposes without your written consent. You can opt out of receiving information about our marketing or fundraisers. We will not sell your health information without your explicit authorization.
- Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders such as voicemail messages, email, postcards, or letters.
- Legal Requirements: We may disclose your health information when required to do so by law.
- Abuse or Neglect: If abuse or neglect is reasonably suspected, we may disclose your health information to the appropriate governmental authorities.
- National Security: When required, we may disclose military personnel health information to the Armed Forces. Information may be given to authorized federal officials when required for intelligence and national security activities. Health information for inmates in custody of law enforcement may be provided to correctional institutes.
- Family Members, Friends, and Others Involved in Care: At your request, we may disclose your health information to a family member or other person if necessary to assist with your treatment and/or payment for services. Based on our judgment and as per 164.522(a) of HIPAA we may disclose your information to these persons in the event of an emergency situation. We also may make information available so that another person may pick up filled prescriptions, medical supplies, records, or x-rays for you. Your information may be disclosed to assist in notifying a family member, caregiver, or personal representative of your location, condition, or death.
- Business Associates: Some services in our organization are provided through contacts with business associates. Examples include practice management software representatives, accountants, answering service personnel, etc. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we have asked them to do and bill you or your third-party payer for services rendered. All of our business associates are required to safeguard your information and to follow HIPAA Privacy Rules.
- Workers’ Compensation: We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.
- Research: We may use or disclose medical information to researchers when an institution’s review board or special privacy board has reviewed the proposed study and established protocols to ensure the privacy of the health information used in their research and determined that the researcher does not need to obtain your authorization prior to using your medical information for research purposes.
- Public Health Activities: We may disclose medical information for public health activities, to include the following: to prevent or control disease, injury, or disability; to report reactions with medications or problems with products, to notify people of recalls of products they may be using; to notify a person who may have been exposed to a disease or who may be at risk for contracting or spreading a disease of condition; to notify the proper government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence (when required by law).
- Other Authorizations: 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.
- Breach Notification: We will notify you any time your PHI may have been compromised through unauthorized acquisition, access, use or disclosure.
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. You must make a request in writing to obtain access to your health information.
We will charge you a reasonable cost-based fee for expenses such as copies. If you request X-Rays, there will be a fee for any copies of films. You are not entitled to originals, only copies. Postage will be added if copies are to be mailed. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Details of all fees are available from the HIPAA Coordinator.
- 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. 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 will keep your information confidential from your health plans if you pay in cash, at your request. In some instances, we may not be required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
- 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.
- Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and must explain the reason for the amendment.) We may deny your request under certain circumstances.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy policy or have questions or concerns, please contact us.
If you have concerns relating to a perceived violation of your privacy rights, to access to your health information, to amending or restricting the use or disclosure of your health information, or to requesting alternative means of communication, you may contact us using the contact information listed at the end of this Notice.
You also may submit a written complaint to the Department of Health and Human Services (HHS). We will provide you with the HHS address 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 HHS.
HIPAA Coordinator: Dr. Marc Chhina
Telephone: 510.724.6900
Email: pinolefamilydental@yahoo.com
Address: 1310 Tara Hills Drive, Suite F Pinole, CA 94564
FINANCIAL POLICY
We are committed to providing you with the best possible care. To help us maintain billing costs to a minimum, we offer the following financial policy. Please understand that payment of your bill is considered a part of your treatment. We require that you read and sign the following financial policy prior to any treatment. If you have any questions, please do not hesitate to ask us.
We accept cash, checks, MASTERCARD/VISA/DISCOVER/AMEX
An appointment, cancelled less than 24 hours or a broken appointment will be charged at a rate of a normal office visit. Please help us serve you better by keeping scheduled appointments.
Returned checks will be subject to additional collection fees and charges.
Minor patients: The adult accompanying a minor and the parents (or guardians of the minor) are responsible for payment.
PAYMENT IS DUE AT THE TIME OF SERVICE:
Patients with dental insurance: We will continue to submit your insurance company. However, we ask that you pay your insurance co-payment at the time of service.
Preventative services – Co-payment is contingent upon individual policies of your plan. Typical co-payment requirement: 0%-20% of our fees.
Basic services -- Co-payment is contingent upon individual policies of your plan. Typical co-payment requirement: 20%-30% of our fees.
Major services – Co-payment is contingent upon individual policies of your plan. Typical co-payment requirement: 50%-60% of our fees.
Note: Any insurance plan that pays directly to the patient, requires payment in full at the time of service, unless prior financial arrangements have been made.
SPECIAL INFORMATION FOR PATIENTS WITH INSURANCE:
We will gladly discuss any questions relating to your insurance.
However, please realize that:
Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract.
Our fees are generally considered to fall within the acceptable range by most companies, and, therefore, are covered up to the maximum allowance determined by each carrier. This applies only to companies who pay a percentage (such as 80%) of UCR. UCR is defined as usual, customary and reasonable fees for this reason. Thus our fees are considered UCR by most companies, unless, your insurance company reimburses based on an arbitrary schedule of fees, which bears no relationship to the current standard and cost of care in this area.
Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover.
As dental care providers, our relationship is with YOU, not your insurance company. While filing of insurance claims is a courtesy that we extend to our patients, all rendered charges are your responsibility from the date of services.
BILLING RIGHTS UNDER THE FAIR CREDIT BILLING ACT:
Late Charge: If your minimum payment is not received by the due date, you may be assessed a late payment charge. The amount of the late charge to be assessed is that maximum amount authorized under the State of CA laws. The late charge will be $5.00 or 5% of the past due minimum payment, whichever is greater, with a maximum of $20.00.
Finance Charge: A finance charge is imposed on those charges not paid in full within 60/90/120 days of the date you were first billed for the charges. The balance on which any finance charge is computed is determined by totaling the charges not paid within the required time period. The finance charge is at a periodic rate of 1.25 percent per month (an ANNUAL PERCENTAGE RATE OF 15 PERCENT). The finance charge is computed by multiplying the balance on which the finance charge is computed by the periodic rate shown above. There is a $0.50 minimum finance charge.
Notify Pinole Family Dental in Case of Errors or Questions About Your Bill: If you think your bill is wrong, or if you need more information about the transaction on your bill, write to our office. We must hear from you no later than 60 days after they have sent you the first bill on which the error or problem appeared. You may telephone us but doing so will not preserve your rights.
In your letter, please provide the following information:
Your name and account number
The dollar amount of the suspected error.
Describe the error and explain, if you can, why you believe there is an error. If you need more information, describe the item you are not sure about.
Your Rights and Pinole Family Dental's Responsibilities After Receiving Your Written Notice:
We must acknowledge your letter within 30 days, unless we have corrected the error by then. Within 90 days, we must either correct or explain why we believe the bill was correct.
After we receive your letter, we can not try to collect any amount you question, or report you as delinquent, we can continue to bill you for the amount you question, including finance charges and we can apply any unpaid amount against your credit limit. You do not have to pay any questioned amount while we are investigating, but you are still obligated to pay the parts of your bill that are not in question.
If we find that they have made a mistake on your bill, you will not have to pay any finance charges related to any questioned amount. If we did not make a mistake, you may have to pay finance charges, and you will have to make up any missed payments on the questioned amount. In either case, we will send you a statement or the amount you owe and the date that it is due.
If you fail to pay the amount that we think you owe, we may report you as delinquent. However, if our explanation does not satisfy you and you write to us within 10 days telling his that you still refuse to pay, we must tell anyone (that we report to) that you have a question about your bill. We must tell you the name of the agency. When the matter is settled between us, we must also notify the agency that the matter is settled. As of 7/1/2025, “A holder of this medical debt contract is prohibited by Section 1785.27 of the Civil Code from furnishing any information related to this debt to a consumer credit reporting agency. In addition to any other penalties allowed by law, if a person knowingly violates that section by furnishing information regarding this debt to a consumer credit reporting agency, the debt shall be void and unenforceable.”
If we do not follow these rules, we can not collect the first $50.00 of the questioned amount even if your bill was correct.
Please call our office if you have any questions concerning your billing rights.
CANCELLATION AND NO-SHOW POLICY
Cancellations and No-shows are taken seriously at our office because it can make the difference between whether you succeed in your dental treatment or not.
Please understand that…
We require 24 hours notice in the event of a cancellation. Our voicemail machine is always on to take your important message. Even if it is a last minute cancellation, we greatly appreciate you notifying us so that we can schedule our "waiting list" patients into your space.
There is a $50 charge for a cancellation without proper notice. This charge will not be covered by insurance, but will have to be paid by you personally.
When a patient does not show as scheduled, three people are hurt:
- The patient because they do not get the treatment they need as recommended by the doctor.
- The doctor who now has a space in the schedule since the time was reserved for the patient personally.
- Another patient who could have been scheduled for treatment if there had been proper notice.
We appreciate your understanding. If you have any questions, please do not hesitate to ask us.
You are encouraged to discuss any and all relevant health issues prior to your treatment.
