All of the above information is correct to the best of my knowledge. I authorize the use of this form on all my insurance submissions and I authorize the release of information to all my insurance companies. I understand that I am responsible for my bill. I authorize Hanosh and Hunter Dental Group to act as my agent in helping me obtain payment from my insurance companies. I authorize payment to Hanosh and Hunter Dental Group. I permit a copy of this authorization to be used in place of the original. I give Hanosh and Hunter Dental Group, its employees, and/or other agents express prior consent to contact me at any/all phone numbers, including cell numbers (by phone call or text message) and email addresses, for the purpose of treatment, insurance, or payment.

I hereby authorize the doctor or designated staff to take X-rays, study models, photographs, and other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the dental needs of the above-named patient.

Upon such diagnosis, I authorize the doctor or designated staff to perform all recommended treatment mutually agreed upon by us and to employ such assistance as required to provide proper care.

 

I agree to the use of anesthetics, sedatives, and other medications as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.

 

I have read, understood, and agree to the above treatment policy.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review the following carefully.
The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. The Act gives you, the patient, significant new rights to understand and control how your information is used. HIPAA provides penalties for covered entities that misuse personal health information.
As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.
We may use and disclose your medical records for several purposes, including treatment, payment, defense of legal matters, to family and friends, and health care operations:

 

• Treatment includes providing, coordinating, and/or managing health care related services by one or more health care providers. An example of this would include teeth cleaning services.
• Payment includes such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a claim for your visit to your insurance company for payment.
• Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review. We may also create and distribute de-identified health information by removing all references to individually identifiable information.
• To Your Family and Friends: We may disclose your health information to a family member, friend, or another person to the extent necessary to help with your healthcare or with payment for your healthcare. Before we disclose your health information to these people, we will provide you with an opportunity to object to our use or disclosure. If you are not present, or in the event of your incapacity or an emergency, we will disclose your medical information based on our professional judgment of whether the disclosure would be in your best interest. We may 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. We may use or disclose information about you to notify or assist in notifying a person involved in your care, of your location and general condition.

 

In some limited situations, the law allows or requires us to use/disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are: 

 

• When a state or federal law mandates that certain health information be reported for a specific purpose
• For public health purposes, such as contagious disease reporting, investigation or surveillance, and notices to and from the federal Food and Drug Administration regarding drugs or medical devices
• Disclosures to governmental authorities about victims of suspected abuse, neglect, or domestic violence
• Uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws
• Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies
• Disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office, or to report a crime that happened somewhere else
• Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations
• Uses or disclosures for health-related research
• Uses and disclosures to prevent a serious threat to health or safety
Uses or disclosures for specialized government functions, such as for the protection of the president or high-ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service
• Disclosures of de-identified information
• Disclosures relating to worker's compensation programs
• Disclosures of a "limited data set" for research, public health, or health care operations
• Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures
• Disclosures to "business associations" who perform health care operations for our office and who commit to respect the privacy of your health information

 

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. If you wish to be omitted from any mailings please provide a written notice. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.
You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

 

• The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
• The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
• The right to inspect and copy your protected health information.
• The right to amend your protected health information.
• The right to receive an accounting of disclosures of protected health information.
• The right to obtain a paper copy of this notice from us upon request.

The Dental Board of California Dental Materials Fact Sheet Adopted by the Board on October 17, 2001. As required by Chapter 801, Statutes of 1992, the Dental Board of California has prepared this fact sheet to summarize information on the most frequently used restorative dental materials. Information on this fact sheet Is Intended to encourage discussion between the patient and dentist regarding the selection of dental materials best suited or the patient's dental needs. It is not intended to be a complete guide to dental materials science. The most frequently used materials in restorative dentistry are amalgam, composite resin, glass ionomer cement, resin-ionomer cement, porcelain (ceramic), porcelain (fused-to-metal), gold alloys (noble) and nickel or cobalt-chrome (base-metal) alloys. Each material has its own advantages and disadvantages, benefits and risks. These and other relevant factors are compared in the attached matrix titled Comparisons of Restorative Dental Materials. A Glossary of Terms is also attached to assist the reader in understanding the terms used. The statements made are supported by relevant, credible dental research published mainly between 1993- 2001. In some cases, where contemporary research is sparse, we have indicated our best perceptions based upon information that predates 1993. The reader should be aware that the outcome of dental treatment or durability of a restoration is not solely a function of the material from which the restoration was made. The durability of any restoration is influenced by the dentist's technique when placing the restoration, the ancillary materials used in the procedure, and the patient's cooperation during the procedure. Following the restoration of the teeth, the longevity of the restoration will be strongly influenced by the patient's compliance with dental hygiene and home care, their diet, and chewing habits. Both the public and the dental profession are concerned about the safety of dental treatment and any potential health risks that might be associated with the materials used to restore the teeth. All materials commonly used (and listed in this fact sheet) have been shown through laboratory and clinical research, as well as through extensive clinical use to be safe and effective for the general population. The presence of these materials in the teeth does not cause adverse health problems or the majority of the population. There exist a diversity of various scientific opinions regarding the safety of mercury dental amalgams. The research literature in peer-reviewed scientific journals suggests that otherwise healthy women, children, and diabetics are not at increased risk for exposure to mercury from dental amalgams. Although there are various opinions with regard to mercury risk in pregnancy, diabetes, and children, these opinions are not scientifically conclusive and therefore the dentist may want to discuss these opinions with their patients. There is no research evidence that suggests pregnant women, diabetics and children are at increased health risk from dental amalgam fillings in their mouth. A recent study reported In the JADA factors in a reduced tolerance (1150th of the WHO safe limit) or exposure in calculating the amount of mercury that might be taken in from dental fillings. This level falls below the established safe limits for exposure to a low concentration of mercury or any other released component from a dental restorative material. Thus, while these subpopulations may be perceived to be at increased health risk from exposure to dental restorative materials, the scientific evidence does not support that claim. However, there are individuals who may be susceptible to sensitivity, allergic or adverse reactions to selected materials. As with all dental materials, the risks and benefits should be discussed with the patient, especially with those in susceptible populations. There are differences between dental materials and the individual elements or components that compose these materials. 

For example, dental amalgam filling material is composed mainly of mercury (43-54%) and varying percentages of silver, tin, and copper (46-57%). It should be noted that elemental mercury is listed on the Proposition 65 list of known toxins and carcinogens. Like all materials in our environment, each of these elements by themselves is toxic at some level of concentration if they are taken into the body. When they are mixed together, they react chemically to form a crystalline metal alloy. Small amounts of free mercury may be released from amalgam fillings over time and can be detected in bodily fluids and expired air. The question is whether any free mercury is present importin sufficient levels to pose a health risk. Toxicity of any substance is related to dose, and doses of mercury or any other element that may be released from dental amalgam fillings fall far below the established safe levels as Stated in the 1999 US Health and Human Sevice Toxicological Profile or Mercury Update. All dental restorative materials (as well as all materials that we come in contact within our daily life) have the potential to elicit allergic reactions in hypersensitive individuals. 1 These must be assessed on a case-by-case basis, and susceptible Individuals should avoid contact with allergenic materials. Documented reports of allergic reactions to dental amalgam exist (usually manifested by transient skin rashes in individuals who have come into contact with the material), but they are atypical. Documented reports of toxicity to dental amalgam exist, but they are rare. There have been anecdotal reports of toxicity to dental amalgam and as with all dental material risks and benefits of dental amalgam should be discussed with the patient, especially with those in susceptible populations. Composite resins are the preferred alternative to amalgam in many cases. They have a long history of biocompatibility and safety. Composite resins are composed of a variety of complex Inorganic and organic compounds, any of which might provoke an allergic response in susceptible individuals. Reports of such sensitivity are atypical. However, there are individuals who may be susceptible to sensitivity, allergic or adverse reactions to composite resin restorations. The risks and benefits of all dental materials should be discussed with the Patient, especially with those in susceptible populations. Other dental materials that have elicited significant concern among dentists are nickel-chromium-beryllium alloys used predominantly or crowns and bridges. Approximately 10% of the female population is alleged to be allergic to nickel. 2 The incidence of allergic response to dental restorations made from nickel alloys is surprisingly rare. However, when a patient has a positive history of confirmed nickel allergy, or when such hypersensitivity to dental restorations is suspected, alternative metal alloys may be used. Discussion with the patient of the risks and benefits of these materials is indicated. Dental Amalgam: A scientific review and recommended public health service strategy for research, education and regulation, Dept of Health and Human Sevices, Public Health Sevice, January 1993.2 Merck Index 1983. Tenth Edition, M Marsha Windhol, Z (ed). I acknowledge that I have received and read The Dental Material Facts Sheet from The Dental Board of California dated October 2001 as provided by Hanosh and Hunter Dental Group. 

MEDICARE PRIVATE CONTRACT "OPT-OUT" AFFIDAVIT I, George Scott Hanosh, DDS, Inc. /G. Scot Hanosh, DDS, Inc., and/or Gregory Beau Hunter, DDS, Inc. /G. Beau Hunter, DDS, attest that under the penalty of perjury the following is true and correct to the best of my knowledge, information and belief: Except for emergency or urgent care services (specified in 42 C.F.R. 405.440), during the opt-out period, I will provide services to Medicare beneficiaries only through private contracts that meet the criteria of paragraph 42 C.F.R. 405.415 or services that, but for their provision under a private contract, would have been Medicare covered services. I will not submit a claim to Medicare or any item or service furnished to any Medicare beneficiary during the two-year period beginning on the following effective date: January 30, 2016 (the "opt out period"), nor will 1, or any entity acting on my behalf, submit a claim to Medicare or services furnished to a Medicare beneficiary during this two-year period, except as specified in 42 C.F.R. 405.440. I understand that during the opt-out period, I may receive no direct or indirect Medicare payment or services that !furnish to Medicare beneficiaries with whom I have privately contracted, whether as an individual, an employee of an organization, a partner in a partnership, under a reassignment of benefits, or as payment for a service furnished to a Medicare beneficiary under a Medicare Advantage (formerly called Medicare Choice) plan. I acknowledge that, during the opt-out period, my services are not covered under Medicare and no Medicare payment may be made to any entity or my services, directly or on a capitated basis. I promise that, during the opt-out period, I will be bound by the terms of both this affidavit and the private contract(s) into which I have entered with a Medicare beneficiary. I acknowledge that the terms of this affidavit apply to all Medicare-covered items and services furnished to Medicare beneficiaries by me during the opt-out period (except for emergency or urgent care services furnished to the beneficiaries with whom I have not previously privately contracted ) without regard to any payment arrangements I may make. I have signed a Pat B participation agreement, and I acknowledge that such agreement terminates on the effective date of this affidavit. (This provision is not required or physicians who have not signed a Medicare Part B participation agreement.) I understand that a beneficiary who has not entered into a private contract and who requires emergency or urgent care services may not be asked to enter into a private contract with respect to receiving such services and that the rules of 42
C.F.R. 405.440 apply if I furnish such services. I understand that I must file this affidavit with all carriers who have jurisdiction over claims that I would otherwise file with Medicare and that this affidavit must be filed no later than ten days after the first private contract to which this affidavit applies is entered into. 1134143373 -G. Scott Hanosh, DDS, Inc. National Provider Identifier (NPI) 1326323270 - G. Beau Hunter, DDS, Inc. National Provider Identifier (NPI)