Appointment Policy
The staff at Willow Pediatric Dentistry is committed to providing the highest quality of dental care to our patients. We will do our best to accommodate your schedule and dental needs. Your scheduled appointment is saved exclusively for you, and we have prepared in advance for your visit. Please be advised of the following scheduling policies.
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We require 48 hours notice for a cancelled or rescheduled appointment. We understand emergencies happen, and they will be taken into consideration. When 48 hour notice is given, we are able to offer the appointment to another patient in need of dental care.
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If the appointment is cancelled or rescheduled without a 48 hour notice, we reserve the right to charge $50.00 per occurrence. The $50.00 fee will need to be paid before future visits in our office.
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If you have 3 or more missed or cancelled appointments without a 48 hour notice, within one year time frame, we reserve the right to dismiss you and your family from the practice.
Treatment Room Policy
The staff at Willow Pediatric Dentistry is committed to providing the highest quality of dental care to our patients. We encourage our parents to enable their children to complete treatment on their own and be proud of their accomplishments. We take great care in building trust with your child and helping them learn how to be great dental patients even when it is not easy all the time. If there is ever a problem that we cannot help the child with, we will have the parent join the team effort to help, and together we will figure out how best to proceed.
No child is the same and may respond differently depending on the time of day or situations in their lives and sometimes, everyone can have a bad day. Therefore, there are times when a parent may be asked or may need to accompany their child into the operatory from the onset of treatment. One parent may be invited to stay in the treatment room with their child, however, we ask that all siblings stay in the waiting room and be accompanied by a parent or guardian. As we try to build rapport with your child, we ask that you be a silent observer while in the treatment area. This way your child can focus on what we need to accomplish, be able to communicate with us and be able to respond to direction.
We ask for your cooperation in providing the best dental environment possible. Due to patient and practitioner privacy laws, no video or pictures are allowed in treatment areas. If you need to use your cell phone during their appointment, you are welcome to do so in the reception area.
Late Policy
We strive to stay on time and are devoted to the children we serve. Occasionally emergencies do arise and we may have to provide unforeseen procedures. Our staff will do our best to communicate to you if we are running behind and appreciate your understanding.
If you are more than 10 minutes late, it may be necessary to reschedule your child’s appointment. If our schedule allows, we will try to accommodate you, however, you may have a wait. We value your time and hope you value you ours as well.
Privacy Policy
Protected health information (PHI), about you, is maintained as a written and/or electronic record of your contacts or visits for
healthcare services with our practice. Specifically, PHI is information about you, including demographic information (i.e., name,
address, phone, etc.), that may identify you and relates to your past, present or future physical or mental health condition and related
healthcare services.
Our practice is legally required to maintain the confidentiality of your PHI, and to follow specific rules when using or disclosing this
information. This Notice describes your rights to access and control your PHI. It also describes how we follow applicable rules when
using or disclosing your PHI to provide your treatment, obtain payment for services you receive, manage our healthcare operations and
for other purposes that are permitted or required by law.
Your Rights Under the Privacy Rule
Following is a statement of your rights, under the Privacy Rule, in reference to your PHI. Please feel free to discuss any questions with
our staff.
You have the right to receive, and we are required to provide you with, a copy of this Notice of Privacy Practices - We are
required by law to follow the terms of this Notice. We reserve the right to change the terms of the Notice, and to make the new Notice
provisions effective for all PHI that we maintain. We will provide you with a copy of our current Notice if you call our office and request
that a copy be emailed or sent to you in the mail, or ask for one at the time of your next appointment. The Notice will also be posted in
a conspicuous location in our practice, and if such is maintained, on the practice’s website.
You have the right to authorize other use and disclosure - This means we will only use or disclose your PHI as described in this
Notice, unless you authorize other use or disclosure in writing. For example, we would need your written authorization to use or
disclose your PHI for marketing purposes, for most uses or disclosures of psychotherapy notes or substance use disorder counseling
notes, or if we intended to sell your PHI. You may revoke an authorization, at any time, in writing, except to the extent that your
healthcare provider, or our practice has taken an action in reliance on the use or disclosure indicated in the authorization.
You have the right to request an alternative means of confidential communication – This means you have the right to ask us to
contact you about medical matters using an alternative method (i.e., email, fax, telephone), and/or to a destination designated by you
(i.e., cell phone number, alternative address, etc.). You must inform us in writing, using a form provided by our practice, how you wish
to be contacted if other than the address/phone number that we have on file. We will follow all reasonable requests.
You have the right to inspect and obtain a copy your PHI* - This means you may submit a written request to inspect or obtain a
copy of your complete health record, or to direct us to disclose your PHI to a third party. If your health record is maintained
electronically, you will also have the right to request a copy in electronic format. We have the right to charge a reasonable, cost-based
fee for paper or electronic copies as established by federal guidelines. We are required to provide you with access to your records
within 30 days of your written request unless an extension is necessary. In such cases, we will notify you of the reason for the delay,
and the expected date when the request will be fulfilled.
You have the right to request a restriction of your PHI* - This means you may ask us, in writing, not to use or disclose any part of
your protected health information for the purposes of treatment, payment or healthcare operations. If we agree to the requested
restriction, we will abide by it, except in emergency circumstances when the information is needed for your treatment. In certain cases,
we may deny your request for a restriction. You will have the right to request, in writing, that we restrict communication to your health
plan regarding a specific treatment or service that you, or someone on your behalf, has paid for in full, out-of-pocket. We are not
permitted to deny this specific type of requested restriction.
You have the right to request an amendment to your protected health information* - This means you may submit a written
request to amend your PHI for as long as we maintain this information. In certain cases, we may deny your request.
You have the right to request a disclosure accountability* - You may submit a written request for a listing of disclosures we have
made of your PHI to entities or persons outside of our practice except for those made upon your request, or for purposes of treatment,
payment or healthcare operations. We will not charge a fee for the first accounting provided in a 12-month period.
You have the right to receive a privacy breach notice - You have the right to receive written notification if the practice discovers a
breach of your unsecured PHI and determines, through a risk assessment, that notification is required.
How We May Use or Disclose Protected Health Information
Following are examples of uses and disclosures of your protected health information that we are permitted to make. These examples
are not meant to be exhaustive, but to describe possible types of uses and disclosures.
Treatment - We may use and disclose your PHI to provide, coordinate, or manage your healthcare and any related services. This
includes the coordination or management of your healthcare with a third party that is involved in your care and treatment. For example,
we would disclose your PHI, as necessary, to a pharmacy that would fill your prescriptions. We will also disclose PHI to other
healthcare providers who may be involved in your care and treatment.
Payment - Your PHI will be used, as needed, to obtain payment for your healthcare services. This may include certain activities that
your health insurance plan may undertake before it approves or pays for the healthcare services we recommend for you such as,
making a determination of eligibility or coverage for insurance benefits.
Healthcare Operations - We may use or disclose your PHI as needed to support the business activities of our practice. This includes,
but is not limited to business planning and development, quality assessment and improvement, medical review, legal services, auditing
functions and patient safety activities.
Special Notices - We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment. We may contact
you by phone or other means to provide results from exams or tests, to provide information that describes or recommends treatment
alternatives regarding your care, or to provide information about health-related benefits and services offered by our office.
Fundraising - We may contact you regarding fundraising activities, but you will have the right to opt out of receiving further fundraising
communications. Each fundraising notice will include instructions for opting out. In addition, if we intend to use or disclose your PHI that
is subject to 42 CFR Part 2 regulations for fundraising purposes, you will first be provided with a clear and conspicuous opportunity to
elect not to receive any fundraising communications.
Health Information Organization - The practice may elect to use a health information organization, or other such organization to
facilitate the electronic exchange of information for the purposes of treatment, payment, or healthcare operations.
To Others Involved in Your Healthcare - Unless you object, we may disclose to a member of your family, a relative, a close friend or
any other person that you identify, your PHI that directly relates to that person’s involvement in your healthcare. If you are unable to
agree or object to such a disclosure, we may disclose such information as necessary if we determine, based on our professional
judgment, that it is in your best interest. We may use or disclose PHI to notify or assist in notifying a family member, personal
representative or any other person that is responsible for your care, of your general condition or death. If you are not present or able to
agree or object to the use or disclosure of PHI (e.g., in a disaster relief situation), then your healthcare provider may, using professional
judgment, determine whether the disclosure is in your best interest. In this case, only the PHI that is necessary will be disclosed.
Other Permitted and Required Uses and Disclosures - We are also permitted to use or disclose your PHI without your written
authorization, or providing you an opportunity to object, for the following purposes: if required by state or federal law; for public health
activities and safety issues (e.g. a product recall); for health oversight activities; in cases of abuse, neglect, or domestic violence; to
avert a serious threat to health or safety; for research purposes; in response to a court or administrative order, and subpoenas that
meet certain requirements; to a coroner, medical examiner or funeral director; to respond to organ and tissue donation requests; to
address worker’s compensation, law enforcement and certain other government requests, and for specialized government functions
(e.g., military, national security, etc); with respect to a group health plan, to disclose information to the health plan sponsor for plan
administration; and if requested by the Department of Health and Human Services in order to investigate or determine our compliance
with the requirements of the Privacy Rule.
Prohibited Uses/Disclosures - Patient records subject to Part 2 regulations may be used or disclosed only as permitted by Part 2 and
HIPAA regulations. Substance use disorder treatment records received from Part 2 programs, or testimony relaying the contents of
such records, will not be used or disclosed in any criminal investigation, to initiate or substantiate criminal charges, or in civil, criminal,
administrative or legislative proceedings by any federal, state, or local authority against you without your authorization or a court order
with accompanying subpoena or similar legal mandate compelling disclosure.
Redisclosure – Protected health information that is disclosed pursuant to the Privacy Rule may be subject to redisclosure and no
longer protected by the Privacy Rule. For example, if a disclosure is made to a third party who is not subject to HIPAA rules (e.g., is not
a healthcare provider, health plan, or healthcare clearinghouse), this entity may redisclose the PHI to others without restrictions.
Privacy Complaints
You have the right to complain to us, or directly to the Secretary of the Department of Health and Human Services if you believe your
privacy rights have been violated by us. We will not retaliate against you for filing a complaint.