We, the staff of Advanced Prosthodontics and Periodontics, thank you for choosing us as your dental provider. We believe your understanding of our patients’ financial responsibility is vital to that provider-patient relationship and our goal is not only to inform you of the provisional aspects of that financial policy but also to keep the lines of communication open regarding them.
If you do not have insurance, proof of insurance, or participate in a plan that will not honor an assignment of insurance benefits, payment for services will be due at the time of service unless a payment arrangement has been approved in advance by our staff.
Payment Methods
We make payment as convenient as possible by accepting (Cash, Visa, Mastercard, American Express and checks). A $35.00 service fee will be charged for all returned checks. Additionally, you may authorize us to keep your credit card on file for your convenience knowing that we adhere to the highest level of information security.
Dental Insurance
Please remember that your insurance policy is a contract between you and your insurance carrier. We will, as a courtesy, bill your insurance and help you receive the maximum allowable benefit under your policy. We have found that patients who are involved with their claims process are more successful at receiving prompt and accurate payment services from their insurance carrier. We do expect patients to be interactive and responsible for communicating with your insurance carrier on any open claims.
It is your responsibility to provide all necessary insurance eligibility, identification, authorization and referral information and to notify our office of any information changes when they occur. Even a preauthorization of services does not guarantee payment from your insurance carrier. We also require photo identification when accepting insurance information. It is the patient’s responsibility to know if our office is participating or non-participating with their insurance plan. Failure to provide all required information may necessitate patient payment for all charges. When insurance is involved, we are contractually obliged to collect copayments, coinsurance, and deductibles, as outlined by your insurance carrier.
Please be aware that out-of-network insurance carriers often prohibit assignment of benefits and may try to limit their financial liability with arbitrary limits, exclusions, or reductions such as reasonable and customary or usual and prevailing reductions. Our fees are well within such ranges and although we will assist in the filing of an appeal if these limitations are imposed, you as the guarantor are responsible for all out-of-network fees. If we are not contracted with your carrier, we will not negotiate reduced fees with your carrier.
Our goal is to provide the best quality dental care possible in a timely manner. In order to do so, we have implemented a new cancellation/no-show policy. This policy enables us to better utilize available appointment for those patients in severe pain needing immediate care and attention.
Cancellation of an Appointment:
In order to be respectful of the dental needs of other patients, please be courteous and call the office promptly if you are unable to attend your appointment. This appointment time will be reallocated to someone who is in urgent need of treatment.
If it is necessary to cancel/reschedule your scheduled appointment, we require that you call at least 24 hours in advance.
How to Cancel/Reschedule Your Appointment:
To cancel appointments, please call our office at 201-652-7711. If you do not reach the receptionist, you may leave a detailed message on the voice mail. You may also email us at smile@appdental.com. If you would like to reschedule your appointment, please be sure to leave us your phone number and let us know the best time to return your call.
No-Show Policy:
A “no-show” is someone who misses an appointment without calling 24 hours in advance to cancel. “No-shows” cause inconvenience to those individuals who need access to emergency dental care in a timely manner, as well as to the physician and staff. A failure to show at the time of a scheduled appointment will be recorded in the patient’s chart as a “no-show”. The “no-shows” will result in a no-show fee of $75. If a patient accumulates 3 “No-shows”, he or she may be asked to leave the practice.
Late Cancellations:
Late cancellations are appointments cancelled less than 24 hours in advance. Exceptions will only be made in extraordinary circumstances. Cancellations made more than 24 hours in advance of your scheduled appointment time will not be assessed a cancellation fee. The “Late-Cancellations” will result in a fee of $50.
Please remember that you may also be the one in need of urgent dental care. We would like to provide the best and fair dental care to all our patients. Thank you for your understanding.
THIS NOTICE DESCRIBES HOW HEALTH AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH AND
MEDICAL INFORMATION IS IMPORTANT TO US.
OUR RESPONSIBLITIES
We at Caleb & Tyler Kim DDS LLC understand that medical information about you and your health is personal. Applicable
federal and state law requires us to maintain the privacy of your health information. We are also required to give you this
Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the
privacy practices that are described in this Notice while it is in effect. This Notice takes effect 08/08/2017, and will remain in
effect until we replace it. We will let you know promptly if a breach occurs that may have compromised the privacy or security
of your information. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided
such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new
terms of our Notice effective for all health information that we maintain, including health information we created or received
before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and
make the new Notice available upon request. You may request a copy of our Notice at any time. For more information about
our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this
Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We may use and disclose health information about you for treatment, payment and healthcare operations. For example:
To Treat You: We can use or disclose your health information to a physician or other healthcare provider providing treatment
to you.
Billing and Payment For Services: We can use and disclose your health information to obtain payment for services we
provide to you.
Healthcare Operations: We can use and disclose your health information in connection with our healthcare operations
which include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare
professionals, evaluating practioner and provider performance, conducting training programs, accreditation, certification,
licensing or credentialing activities.
Notice of Privacy Practices
Your Authorization: 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 our health
information for any reason except those described in this Notice.
To Your Family and Friends: We must disclose your health information to you as described in the Patient Rights section of
this Notice. 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, but only if you agree that we may do so.
Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including
identifying or locating) a family member, your personal representative or another person responsible for your care, of your
location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we
will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency
circumstances, we will disclose health information based on determination using our professional judgment disclosing only
health information that is directly relevant to the person’s involvement in your healthcare. We will also 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.
Marketing Health-Related Services: We will not use your health information for marking purposes without your written
permission.
Required by Law: We may use or disclose your health information when we are required to do so by state or federal law,
including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.
Abuse or Neglect: We may disclose your health information when we are required to do by state or federal law, including
with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain
circumstances. We may disclose to authorized federal officials health information required for lawful intelligence,
counterintelligence, and other national security activities. WE may disclose to correctional institution or law enforcement
official having lawful custody of protected health information of inmate or patient under certain circumstances.
Respond to organ and tissue donation requests: We can share health information about you with organ procurement
organizations.
Notice of Privacy Practices
Work with a medical examiner or funeral director: We can share health information with a coroner, medical examiner, or
funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests: We can use or share health
information about you:
• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services.
Respond to lawsuits and legal actions: We can share health information about you in response to a court or administrative
order, or in response to a subpoena.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such
as voicemail messages, postcards, text messages, emails or letters).
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. You may obtain a form to request access by
using the contact information listed at the end of this Notice, If you request an alternative format, we will charge a cost-based
fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your
health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee
structure.)
Disclosure Accounting: 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, but not before April 14, 2003. 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 are not required to agree to these additional restrictions, but if we do, we will abide by our agreement
(except in an emergency).
Notice of Privacy Practices
Alternative Communication: You have the right to request that we communicate with you about your health information by
alternative means or at 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 it
must explain why the information should be amended.) We may deny your request under certain circumstances.
Electronic Notice: If you receive this Notice on our Website or by electronic mail (e-mail), you are entitled to receive this
Notice in written form.
QUESTIONS OR COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us.
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to
your health information or in response to a request you made to amend or restrict the use or disclosure of your health
information or to have us communicate with you by alternative means or at alternative locations, you may complain to us
using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department
of Health and Human Services by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-
696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
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 U.S. Department of Health and Human Services.
Privacy Officer: Caleb Kim
Telephone: 201-652-7711
E-mail: smile@apnpdental.com
Address : 119 First St. Suite 2
City: Ho-Ho-Kus
State: New Jersey
Zip Code: 07423