Medical Form Terms and Conditions

General

I understand that the information that I have provided today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence, and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

This office reserves the right to verify the credit status of potential patients and/or the legal guardians of patients prior to extending credit for treatment fees and may, at the discretion of the office, use the services of one or more credit reporting services.

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any copayment and deductibles that my insurance does not cover.

Text and Email Policy

Square Smiles Orthodontics affiliated offices can email and/or text you appointment reminders and general information about our services. By signing below, you consent to receive appointment reminders and other communications/information via email or text from our practice sent to any email address or phone number you provide to us. To opt-out at any moment, reply ‘STOP’. Any email or text messages we send may not be encrypted or otherwise protected and could be intercepted by a third party. By executing this consent, you assume the risk that the information contained in any such communication will be intercepted. We will not charge you for sending texts or emails, but charges from your carrier may apply. I understand that this request to receive emails and/or text messages will apply to all future appointment reminders and communications sent by our practice until I request a change in writing.

Appointment Policy

Policy for Cancellations: Notify us no later than 24 hours (one business day) prior to your reservation to avoid being assessed a $55 late cancellation fee.

At Square Smiles, our goal is to offer every patient exceptional care and service. We view booked reservations as an opportunity to deliver care to our patients in a timely manner. Your treatment plan is provided as a series of reservations over a pre-planned time frame. It is important that you show up to each appointment to achieve optimal results. As a result, we have implemented a few guidelines to follow whenever it is necessary to reschedule an appointment:

1. If you are unable to make a scheduled appointment due to an emergency, please call us at 617-533-8058. We can help you reschedule.
2. For cancellations, please give us 24 hours notice, at least one business day, prior to your or your child’s scheduled appointment.
3. We charge $55 per missed or cancelled appointment without a minimum of one-business day advance notice Monday to Friday (weekend notifications are not accepted since our office is closed).
4. Our $55 missed or late cancellation fee must be paid in full prior to reserving another appointment (for any and all family members).
5. Presenting more than 15 minutes late for a confirmed appointment may be considered a “missed appointment”.
6. No walk-ins allowed.
7. New patients with two or more missed or cancelled treatment appointments will not be able to make future reservations. If you are a patient currently in treatment and miss two or more appointments, you risk having treatment terminated for poor compliance and excessively missed appointments.
8. Any appointment that remains unconfirmed via phone call/email/text 24 hours prior to the scheduled appointment may be subject to automatic cancellation by Square Smiles.

Policies for Patients of Square Smiles

Orthodontic treatment is a team effort requiring close cooperation between the patient, doctor, and parents of minor patients. We request your cooperation with us in the following areas:

• Check-In/Patient Updates: Adult patients and parents of minor patients receiving treatment are requested to check in at the front desk for all appointments. Any changes in a patient’s medical history must be reported to either the staff at the front desk, the Orthodontist, or an orthodontic assistant.
• Parents and Visitors: Once active orthodontic treatment has begun on patients, we request that unless you are the patient being treated or the Orthodontist asks you to remain in the treatment area, you please wait in the reception area.
• Hygiene: Great hygiene results in healthy teeth and gums. Patients should follow the directions provided concerning proper brushing and hygiene techniques. Poor oral hygiene can lead to decalcification and white spots on the teeth. We cannot assume responsibility for such problems due to poor hygiene.
• School Hours Appointments: Must be made for certain orthodontic procedures due to their length and nature. In order to accommodate more patients with after-school time, we only allow shorter appointments after 2:30 PM.
• Diet: Patients are instructed to avoid foods that are sweet, sticky, and hard. Patients are requested to avoid excessive intake of sweet foods with refined carbohydrates. Too many sweets will lead to decay and white spots on the teeth. We cannot assume responsibility for such problems due to poor diet.
• Broken Appliances: Fortunately, most patients experience minimal breakage. We request that patients follow our instructions concerning diet and care for appliances. Extensive breakage can prolong treatment and affect the quality of care. If a bracket or band breaks or becomes loose, please notify our office. There will be a charge of $55.00 for each broken bracket or band after three occurrences or three or more brackets at an appointment.
• Length of Treatment: Treatment time varies from patient to patient. We try to estimate as accurately as possible the length of treatment for our patients. There are variables that will affect the time of treatment such as growth, cooperation, etc. Exact treatment time is impossible to predict and estimate. It is within the Orthodontist’s complete discretion to determine when treatment has been completed.
• Respectful Relationship: Patients, parents, or any visitor to this office will be treated in a professional, polite, and respectful manner. The same behavior is expected of patients and patrons of this office.
• Insurance Coverage: It is the parent and/or patient’s responsibility to ensure that the patient remains eligible and covered for orthodontic services by their insurance carrier during the course of treatment. If a patient loses their orthodontic benefit during treatment, or the insurance carrier does not pay for the treatment, the balance remaining on the account will be the responsibility of the patient/parent/guardian.
• VI. Your Written Authorization for Any Other Use or Disclosure of Your Health Information
  Uses and disclosures of your protected health information that involve the release of psychotherapy notes (if any), marketing, sale of your protected health information, or other uses or disclosures not described in this notice will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke this authorization at any time, in writing, except to the extent that this office has taken an action in reliance on the use of disclosure indicated in the authorization. If a use or disclosure of protected health information described above in this notice is prohibited or materially limited by other laws that apply to use, we intend to meet the requirements of the more stringent law.
  
  VII. Your Rights with Respect to Your Health Information
  You have the following rights with respect to certain health information that we have about you (information in a Designated Record Set as defined by HIPAA). To exercise any of these rights, you must submit a written request to our Privacy Official listed on the first page of this Notice.
  A. Right to Access and Review
  You may request to access and review a copy of your health information. We may deny your request under certain circumstances. You will receive written notice of a denial and can appeal it. We will provide a copy of your health information in a format you request if it is readily producible. If not readily producible, we will provide it in a hard copy format or other format that is mutually agreeable. If your health information is included in an Electronic Health Record, you have the right to obtain a copy of it in an electronic format and to direct us to send it to the person or entity you designate in an electronic format. We may charge a reasonable fee to cover our cost to provide you with copies of your health information.
  B. Right to Amend
  If you believe that your health information is incorrect or incomplete, you may request that we amend it. We may deny your request under certain circumstances. You will receive written notice of a denial and can file a statement of disagreement that will be included with your health information that you believe is incorrect or incomplete.
  C. Right to Restrict Use and Disclosure
  You may request that we restrict uses of your health information to carry out treatment, payment, or health care operations or to your family member or friend involved in your care or the payment for your care. We may not (and are not required to) agree to your requested restrictions, with one exception: If you pay out of your pocket in full for a service you receive from us and you request that we not submit the claim for this service to your health insurer or health plan for reimbursement, we must honor that request.
  D. Right to Confidential Communications, Alternative Means and Locations
  You may request to receive communications of health information by alternative means or at an alternative location. We will accommodate a request if it is reasonable and you indicate that communication by regular means could endanger you. When you submit a written request to the Privacy Official listed on the first page of this Notice, you need to provide an alternative method of contact or alternative address and indicate how payment for services will be handled.
  E. Right to an Accounting of Disclosures
  You have a right to receive an accounting of disclosures of your health information for the six (6) years prior to the date that the accounting is requested except for disclosures to carry out treatment, payment, health care operations (and certain other exceptions as provided by HIPAA). The first accounting we provide in any 12-month period will be without charge to you. We may charge a reasonable fee to cover the cost for each subsequent request for an accounting within the same 12-month period. We will notify you in advance of this fee and you may choose to modify or withdraw your request at that time.
  F. Right to a Paper Copy of this Notice
  You have the right to a paper copy of this Notice. You may ask us to give you a paper copy of the Notice at any time (even if you have agreed to receive the Notice electronically). To obtain a paper copy, ask the Privacy Official.
  G. Right to Receive Notification of a Security Breach
  We are required by law to notify you if the privacy or security of your health information has been breached. The notification will occur by first class mail within sixty (60) days of the event. A breach occurs when there has been an unauthorized use or disclosure under HIPAA that compromises the privacy or security of your health information.
  The breach notification will contain the following information: (1) a brief description of what happened, including the date of the breach and the date of the discovery of the breach; (2) the steps you should take to protect yourself from potential harm resulting from the breach; and (3) a brief description of what we are doing to investigate the breach, mitigate losses, and to protect against further breaches.
  
  VIII. Special Protections for HIV, Alcohol and Substance Abuse, Mental Health and Genetic Information
  Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including HIV-related information, alcohol and substance abuse information, mental health information, and genetic information. For example, a health plan is not permitted to use or disclose genetic information for underwriting purposes. Some parts of this HIPAA Notice of Privacy Practices may not apply to these types of information. If your treatment involves this information, you may contact our office for more information about these protections.
  
  IX. Our Right to Change Our Privacy Practices and This Notice
  We reserve the right to change the terms of this Notice at any time. Any change will apply to the health information we have about you or create or receive in the future. We will promptly revise the Notice when there is a material change to the uses or disclosures, individual’s rights, our legal duties, or other privacy practices discussed in this Notice. We will post the revised Notice on our website (if applicable) and in our office and will provide a copy of it to you on request. The effective date of this Notice is June 5, 2017.
  
  X. How to Make Privacy Complaints
  If you have any complaints about your privacy rights or how your health information has been used or disclosed, you may file a complaint with us by contacting our Privacy Official listed on the first page of this Notice. You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you in any way if you choose to file a complaint.
  
  Acknowledgment of Privacy Practices
  I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly or indirectly, obtain payment from third-party payers, and conduct normal healthcare operations such as quality assessments and physician certifications.
  I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations. I also understand, you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
  
  Acknowledgment
  By signing below, I agree that I have read and understand Square Smiles HIPAA Privacy Policy, Receipt of Notice of Privacy, Financial Policy, and Appointment Cancellation Policy forms and I agree to be bound by its terms. I also understand and agree that such terms may be amended from time-to-time by the practice.
  PATIENT’S AUTHORIZED REPRESENTATIVE
  If you are consenting to the care of another: I have legal authority to sign this.
  {Signature}