Frequently Asked Questions
Yes. Please arrive 15 minutes early to fill out any remaining forms. New patient forms can be found at the bottom of this page.
Dental Insurance Card
New Patient Forms
Time will vary, especially for your first appointment. But please allow at least 1 to 1.5 hours for the first visit.
Many people do not see a dentist on a regular basis. They only go when they have a problem. This is known as “crisis treatment” versus “preventive treatment.” While these patients may feel they are saving money, it often ends up costing much more money and time. This is because many dental problems do not have symptoms until they reach the advanced stages of the disease process. An good example is tooth decay. It is typical to hear, “Nothing hurts so I must not have any problems.” Tooth decay often does not hurt until it gets close to the nerve of the tooth. It is not uncommon to see a patient with a huge cavity who has never felt a thing. The dentist can usually detect a cavity 3-4 years before it develops any symptoms. This early detection can help you prevent costly treatment.
Many diseases of the teeth and surrounding tissues cannot be seen when the dentist examines the mouth. An x-ray examination may reveal:
small areas of decay between the teeth or below existing fillings, infections in the bone, periodontal (gum) disease, abscesses or cysts, developmental abnormalities, and some types of tumors.
Finding and treating dental problems at an early stage can save time, money and unnecessary discomfort. X-rays can detect damage to oral structures not visible during a regular exam. If you have a hidden tumor, X-rays may even help save your life. Our dentist will evaluate your need for X-rays based on the conditions present in development. There are many benefits to having X-rays taken. Any additional questions or concerns should be discussed during your appointment time.
New Patient Forms
Notice of Privacy
COMPLETE DENTAL CLINICS PLC
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
PURPOSE: COMPLETE DENTAL CLINICS PLC, hereafter referred to as “Practice,” follow the privacy practices described in this Notice. The Practice is required by law to maintain the privacy of your health information and to protect the integrity, confidentiality, and availability of your health
information when it is collected, maintained, and transmitted. You may access or obtain a copy according to the following options: 1) our website at
www.completedentalcare.care. 2) contact the office and request a copy to be sent to you by mail or email, 3) request a copy at the time of your next
appointment. This notice takes effect 05/08/2018 and remains in effect until we replace it. Amended Notice of Privacy Practices shall be available on
- USES & DISCLOSURES OF PHI: Your PHI may be used and disclosed by our Practice’s dentist, administrative and or clinical staff and
others outside of our Practice who are involved in your care and treatment for the purpose of providing healthcare services to you. This includes dental records, dental x-rays and payment information. This also includes information such as sensitive information including your social security number, credit card number, and other identifiable information in addition to sensitive medical information such as HIV status.
A) Treatment: We will use and disclose your PHI to provide, coordinate or manage your dental care and any related services. We
may disclose PHI to other providers who may be treating you such as a specialist.
B) Payment: We will use your PHI to obtain payment for the dental care services provided by this Practice. For example, if we are
working with your insurance plan, we may verify eligibility or coverage for benefit determination. We may use or disclose your information
so that a bill may be sent to you that may include services provided.
C) Healthcare Operations: The Practice may use or disclose, as needed, your PHI in order to support its business activities such as
quality performance reviews regarding our services or the performance of our staff. Business Associates: We may share your PHI with third
party business associates such as answering services, transcriptionists, billing services, consultants, trainers and legal counsel. We obtain a
written agreement between our Practice and the business associate to assure the protection and privacy of your PHI. Business Associates
are asked to disclose if they are working with subcontractors.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or
Object: We may use or disclose your PHI in the following situations without your authorization or providing you the opportunity to agree or object as follows:
A) Required or Permitted by Law: We may use or disclose your PHI as required by law. This may include public health activities
such as controlling a communicable disease or compliance with health oversight agencies authorized by law. We may disclose PHI to a public
health authority authorized to receive reports of child abuse or neglect. We may disclose your PHI if we believe you have been a victim of
abuse, neglect or domestic violence to a governmental agency authorized to receive such information in compliance with state and federal
law. We may disclose your PHI to the Food and Drug Administration for the quality, safety, or effectiveness of FDA-regulated products or
activities. We may disclose your PHI in the course of a legal proceeding in response to a subpoena, discovery request or other lawful process.
We may also disclose PHI to law enforcement providing applicable legal requirements are satisfied. We may disclose PHI to a coroner or
medical examiner for identification purposes. We may disclose PHI to researchers when the information does not directly identify you as
the source of the information and such research has been approved by an institutional review board to ensure the privacy of the PHI. We
may disclose PHI as authorized to comply with workers’ compensation laws. We may use and disclose your PHI if you are an inmate of a
correctional facility and this information is necessary for your care.
Authorization for Other Uses and Disclosures of PHI: Use and disclosure of your PHI not addressed in this Notice of Privacy Practices will
be made only with your written authorization. You may revoke this authorization in writing at any time. If you revoke this authorization, we will no longer use or disclose your PHI; however, we are unable to retrieve previous disclosures made with your prior authorization.
Other Permitted and Required Uses and Disclosures that Require Your Permission or Objection:
i) Students: We may share PHI with students working in our Practice to fulfill their educational requirements. If you do not wish a
student to observe or participate in your care, please notify your provider.
ii) Appointment Reminders: We may contact you as a reminder of your appointment. Only limited information is provided on an
answering machine or an individual other than you answering the call. We may issue a post card or letter notifying you that it is time to make
an appointment. You may provide a preferred means of contact such as a mobile telephone number or email address. Reasonable requests
will be accommodated.
iii) Family, Close Friends, Personal Representatives & Care Givers: Our staff may disclose to person involved in your care your PHI
relevant to that person’s involvement in your care or payment of the services providing you identify these individual(s) and authorize the
release of information. If you are unable to agree or object to such disclosure, we may disclosure such information as necessary if we
determine that it is in your best interest based on our professional judgment. If a young adult age eighteen (18) requests that his or her
information not be released to a parent or guardian, we must comply with this request in compliance with state law. For minor children
living in divided households, both parents (mother and father) have access to the PHI unless their parental rights have been terminated.
Payment of services is addressed in your Final Divorce Decree; however, we obtain payment from the parent who brings the child in for
treatment. We will provide you a statement to send to the other parent for your reimbursement.
iv) Emails: Email and other electronic forms of communication may not be encrypted. Such email may compromise the security of
your PHI. If you elect alternative forms of communication, please notify our office.
v) Disaster Relief: If applicable, we may use or disclose your PHI to an authorized public or private entity to assist in disaster relief
efforts and to coordinate uses and disclosures to family or other individuals involved in your care.
- YOUR RIGHTS. The following is a statement of your rights regarding PHI we gather about you:
A) Copy of this Notice: You have the right to a copy of this notice including a paper copy.
B) Inspect and Copy PHI: You have the right to inspect and obtain a copy of PHI about you maintained by our Practice to include
dental and billing records. You must submit a written request and indicate whether you prefer a paper or electronic copy. According to state
and federal law, we may charge you a reasonable fee to copy your records. Our Practice does not transmit unsecure PHI via email. However,
if you prefer this information emailed to you with encryption or security measures, we will comply with your request and will verify your
email address. We suggest sending our Practice an email and we will reply with the attachment. (Note: Under federal law, you may not
inspect or copy psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action
or proceeding. Please contact the Privacy Officer for more details).
C) Amendment: You have the right to have your provider amend your PHI about you in a designated record set. Please consult with
the Privacy Officer. We may deny this request and you may respond with a statement. We may include a rebuttal statement in your record.
Reasons we may deny amending such information, but not limited to these reasons, is if we did not create the information, or if the individual
who created the information is no longer available to make the amendment or it is not part of the information maintained at our Practice.
D) Restrictions: You have the right to request a restriction of your PHI. If you paid out-of-pocket for a service or item, you have the
right to request that information not be disclosed to a health plan for purposes of payment or health care operations and we are required to
honor that request. You may request in writing to our Privacy Officer not to use or disclose any part of your PHI for the purposes of treatment,
payment or health care operations such as to family members or friends involved in your care or for notification purposes as described in
this Notice of Privacy Practices. However, your provider is not required to agree to this restriction. You may discuss restrictions with the
E) Confidential Communications: You have the right to request to receive confidential communications from our Practice by
alternative means or at an alternative location. For example, you may prefer our Practice to use your mobile telephone or email rather than
a residential line. Please make this request in writing to the Privacy Officer. Our staff will not ask personal questions regarding your request.
F) Disclosures: You have the right to request an accounting of disclosures of your PHI including those made through a Business
Associate as set forth in CFR 45 § 164.528. The HITECH Act removed the accounting of disclosures exception to PHI to carry out treatment,
payment and healthcare operations if such disclosures are made through the EHR. To request an accounting, you must submit your request
in writing to the Privacy Officer.
G) Breach Notification: According to the HITECH Act, you have the right to be notified following a breach of unsecured PHI that
affects you. “Unsecured” is information that is not secured through the use of technology or methodology identified by the Secretary of the
U.S. Department of Health and Human Services to render the PHI unusable, unreadable and undecipherable to unauthorized users. Breach
notification applies to our Business Associates who are obligated to notify our Practice if a breach of unsecured PHI occurs that affects you.
H) Fundraising: If PHI is used for fund raising which is considered “health care operations,” basic requirements must be satisfied
to include notice to the individual and a process for individuals to opt-out. If the individual consents, only specific parts of PHI may be used
for fund raising. Note: Your PHI will not be used in this manner at our Practice.
- Complaints: You have the right to file a complaint if you believe your privacy rights or that of another individuals’ have been violated.
You may contact our Privacy Officer and your issue will be addressed. You may also file a complaint with the Secretary of Health and Human Services
at: U.S. Department of Health & Human Services, Office of Civil Rights, 200 Independence Avenue, SW, Washington, D.C. 20201. Your complaint must
be filed in writing, either on paper or electronically, by mail, fax, or e-mail; name the covered entity or business associate involved and describe the
acts or omissions you believe violated the requirements of the Privacy, Security, or Breach Notification Rules; and be filed within 180 days or as
determined by this State when you knew that the act or omission complained of occurred. You may visit the Office of Civil Rights website at www.hhs.gov/ocr/hipaa/ for more information.
If you have any questions, would like additional information or want to report a problem regarding the handling of your PHI, you may contact the
Privacy Officer at:
COMPLETE DENTAL CLINICS PLC
2064 South Highland Ave.
Jackson, TN 38301
- COMPLETE DENTAL CLINICS PLC
- 25 Stone Ridge Cove
- Huntingdon, TN 38344
- COMPLETE DENTAL CLINICS PLC
- 382 Tennessee Avenue North
- Parsons, TN 38363
You will not be penalized for filing a complaint.
Additionally, you may file a complaint with the Secretary of Health and Human Service at:
U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, SW
Room 515 F HHH Building
Washington, DC 20201