Mission Statement

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Mission Statement

  1. 1. www.drcolinrichman.comWelcome to our practice! As specialists, we dedicate ourselves to the oral health of our patients. Asdental health professionals, we dedicate ourselves to the total well being of our patients. We keepabreast of new periodontal, implant and oral reconstruction treatments and continually improve thequality of our patient care. We will make every effort to see that your care is as comfortable aspossible. Most important, we will listen carefully to your oral health concerns and attempt to answerall your questions thoroughly.Please complete the attached Patient Information Forms and email or fax them to our office as soonas possible. This will give us the opportunity to review your information and be adequately preparedfor your visit. Also, if available, bring your completed medical and dental claim forms, as well ascopies of your medical and dental insurance cards. This will enable us to help you obtain the dentalbenefits due to you. We have also attached a Signature Release Statement. This is necessary to forus to request medical and dental information from your Dentist and, if indicated, your physician.Enclosed you will find general literature on Periodontics and Dental Implants. Our patients havefound these brochures helpful in answering their questions about periodontal and dental implant care.Please visit our office website at www.drcolinrichman.com for further information on Periodontics andImplant dentistry.Thank you for selecting us to care for your oral health. We look forward to meeting you. Please call ifyou have any questions.Robin Crawford, Patient Coordinator 1
  2. 2. Mission StatementWe are:Dedicated to providing the highest quality oral health care in a cheerful and caring environment with acommitment to uncompromised personal and professional service for each patient.To our patients:We are committed to honest and open communication to build long-lasting relationships built onmutual respect and trust. Through comprehensive individualized treatment plans, we seek to assurethe wants and needs of each patient are recognized and fulfilled, and instill a desire for achieving andmaintaining optimum oral health.Our patients are the reason we exist as an organization and our objective is to make each patient anambassador for continued growth and success.To our staff:We are committed to the hiring and development of the finest individuals in dentistry and rely on ourknowledge, dedication, and energy to provide superior service. Our quality and performance arebased on teamwork and communication and we provide continuing education for personal andprofessional growth.To our profession:We are committed to remaining at the forefront of dental technology and techniques that make us theleader in our profession. We associate with quality oriented specialists and laboratories that shareour commitment to excellence and contribute greatly to our success.To our community:We are committed to building on our reputation as an organization that gives of its time and talents toenhance the community it serves. 2
  3. 3. REGISTRATION FORM:(W) Work Phone Number: , (H) Home Phone Number: , (F) Fax Number:(C) Cell Phone Number , Other Phone Number: , Email Address:Referred by:Today’s date:Single: Married: Divorced: Separated:Home address: Street, City, State, ZipEmployed by: Occupation:Business address:Spouse employed by: Business phone:Name and phone number of nearest relative not living with you:Whom may we thank for referring you to our office?Dentist’s name:Physician’s name and phone number:Date and reason for last medical/physical examination:Pharmacy name, phone number and address:Other recent dental specialists consulted or pending consultation – why?To avoid misunderstanding regarding insurance, we wish to let our patients know that all professional services arecharged directly to the patient and that the patient is personally responsible for payment of all fees. If you are unable topay for each service at the time it is provided, please make alternative arrangements with our office for a reasonable andpunctual program that will be convenient to you, and enable you to proceed on a timely basis with the treatment you need.Please complete the following, if you want us to process your insurance forms for you to submit to your insurance carrier.Dental Benefits Carrier:Subscriber’s name:Subscriber’s birth date:Subscriber’s employer:Dental benefits carrier, address and phone number:City: State: Zip:Phone:Group policy number: 3
  4. 4. MEDICAL HISTORY:Dental and oral diseases are caused by a combination of complex factors. The following questions are designed to helpus identify them. Although some of the questions may seem unrelated to your dental condition, they are associated ;withproper management of your physical and oral health.Please circle/check all that apply, past and current:* Are you currently under the care of a physician?* Have you been hospitalized or had any serious illnesses within the past 5 years?* Are you currently taking any herbal or homeopathic medications, both short and long-term?* List all medications being taken, and the conditions for which these medications are being taken Include homeopathic, aspirin and over the counter medications as well:* Have you had any major or minor surgery during the past 5 years? Please list:* Do you consider yourself to be in good health?* Rheumatic/Scarlet fever/High/Low blood pressure* Heart problems/attack/stroke/murmur* Bleeding/Clotting/Anemia/Blood diseases/disorders* Thyroid/Parathyroid diseases/disorders* Frequent headaches/Tendency to faint* Tumor/Growth/Cancer* Allergy to Penicillin/Codeine or other medications* Do you bruise easily?* Immunological compromised disease* Diabetes or a family history of diabetes* Kidney problems/Ulcers/Epilepsy/Convulsion* Jaundice/Hepatitis/liver disease* Asthma/Hay fever/Hives/Sinus* Arthritis/Rheumatism/Previous radiation therapy* Tuberculosis/Emphysema/other lung diseases* Venereal disease/gonorrhea/syphilis* Eye disorders or Glaucoma* CPAP machine or any other product to decrease snoring* History of chemical dependency If yes, how long have you been in remission? years Please list all other medical conditions, which affect your health or lifestyle: 4
  5. 5. DENTAL HISTORY:What is the reason for this visit, and what are your objectives in seeking treatment atour office?How long have you been a patient of your current dentist?Date of most recent Dental Treatment?By whom? For what?Any dental treatment by any other dentist or dental specialist during the past 2 years?If yes, by whom and for what reason?How do you feel about dental treatment? Comfortable – Concerned – Anxious - Very anxiousHow many times have you had your teeth cleaned, during the past 3 years?How many times a week do you floss or use toothpicks?Please circle/check all that apply, past and current:* Bad breath – your impression* Have you been told that you may have bad breath* Bleeding gums* Receding gums or sensitive teeth* Food catching between the teeth* Painful gums* Shifting or loose teeth* Tooth clenching or grinding habits* Prefer chewing on one side or difficulty chewing* Previous Periodontal (gum) treatment* Previous orthodontic (braces) treatment* Frequent headaches* Instruction on tooth and gum cares* Concern about losing your teeth* Previous complications with DENTAL treatment* Pain with your TMJ (jaw joints)* Satisfied with your Smile* Satisfied with your bite* Satisfied with the appearance of your teeth and gums* Satisfied with the color of your teeth* Severer snoring or sleep apnea* If yes, is this a problem for you or your partnerSIGNATURE DATE 5
  6. 6. Please sign this form on the space below. Your signature isnecessary for us to:A. Process all medical and dental insurance claims on your behalf.B. Release medical and dental information to insurance companies.C. Release information to other medical and dental providers.D. Request and obtain medical and dental information from your dentist, physician and other health care professionals.I authorize the release of all dental and medical information necessary toprocess my claims and I authorize the release of this same information,when necessary, to other providers rendering medical/dental care.Also, I have received a copy of this office’s Notice of Privacy Practices.SIGNATURE: DATE: 6
  7. 7. CONSENT FOR DISCLOSUREIn general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures oftheir protected health information (PHI). The individual is also provided the right to request confidentialcommunications or that a communication of PHI be made by alternative means, such as sending correspondenceto the individual’s office instead of the individual’s home.I wish to be contacted in the following manner (check all that apply): Home Telephone Written Communication OK to leave message with detailed information OK to mail to my home address Leave message with callback number only OK to mail to my work/office address Work Telephone OK to leave message with detailed information Leave message with call-back number only E Mail Yes E Mail address: ………………………………… No, do not use my email Fax Yes Fax # ………………………………………….. No, do not FaxIf you want other parties to act on your behalf relative to administrativetasks, please list their names and the tasks you would like them to perform.Examples might include: My secretary (full name) might schedule myappointments, or my spouse (full name) will deal with insurance and billingmatters etc. This is a HIPPA regulation and requirement.SIGNATURE: DATE:The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use of disclosure ofand requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do notapply to uses or disclosures made pursuant to an authorization requested by the individual. Note: Uses and disclosure may be permitted without prior consent in an emergency 7
  8. 8. NOTICE OF PRIVACY PRACTICES. Colin S. Richman DMD PCThis notice describes how health information about you may be used and disclosed and how you can get access to thisinformation.Please review it carefully. The privacy of your health information is important to us.OUR LEGAL DUTYWe are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Noticeabout our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are describedin this Notice while it is in effect. This Notice takes effect 09/01/2002, and will remain in effect until we replace it.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 willchange 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, pleasecontact us using the information listed at the end of this Notice.USES AND DISCLOSURES OF HEALTH INFORMATIONWe use and disclose health information about you for treatment, payment, and healthcare operations. For example:Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.Payment: We may use and disclose your health information to obtain payment for services we provide to you.Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations includequality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner andprovider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities.Your Authorization: In addition to our use of you health information for treatment, payment, or healthcare operations, you may give us writtenauthorization to use your health information or to disclose it to anyone for any purpose. If your give us authorization, you may revoke it in writing at anytime. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a writtenauthorization, we cannot use or disclose your 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 maydisclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for yourhealthcare, 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 familymember, 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 you health information, we will provide you with an opportunity to object to such uses or disclosures. In the event ofyour incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosingonly health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and ourexperience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medicalsupplies, x-rays, or other similar forms of health information.Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.Required by Law: We may use or disclose your health information when we are required to do so by law.Abuse of Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse,neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a seriousthreat to your health or safety or the health or safety of others.National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We maydisclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. Wemay disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certaincircumstances.Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages,postcards, or letters).PATIENT RIGHTSAccess: 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 aformat other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtainaccess to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We willcharge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the addressat the end of this Notice. If you request an alternate format, we will charge a cost-based fee for providing your health information in that format. If youprefer, 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 the Noticefor 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 forpurposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If yourequest this accounting more than once in a 12-month period, we may chare you a reasonable, cost-based fee for responding to these additionalrequests.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 toagree 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 toalterative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactoryexplanation how payments will be handled under the alternative means or location you request.Amendment: You have the right to request that we amend you health information. (Your request must be in writing, and it must explain why theinformation should be amended.) We may deny your request under certain circumstances.Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.QUESTIONS AND COMPLAINTSIf 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 orin 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 byalternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submita written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S.Department of Health and Human Services upon request. We support your right to the privacy of you health information. We will not retaliate in anyway if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. 8
  9. 9. DIRECTIONS TO OUR OFFICE:From GA 400, take Mansell Rd Exit (#8); turn left off exit. Proceed towards Alpharetta Highway (approx. 2 miles); turnright on Alpharetta Highway. Proceed northward (Approx. 2 miles) to Hembree Rd; Landmarks are the Nalley Jaguardealership on your right. Turn right on Hembree Rd., and proceed for half a block. We are located on your right, the signat our driveway is 1305 Hembree Place.From Roswell or Alpharetta, proceed on Alpharetta Highway to Hembree Rd., and then follow directions above. 9

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