INSURANCE AND PAYMENT OPTIONS

We accept payments from most dental insurances. If you provide your insurance information to us, we can confirm if your insurance will help pay for your treatment prior to your first visit to our office. We accept Cash, Checks, American Express, Discover, Mastercard or Visa.

Dental Insurance is different from Medical Insurance. Many patients aren’t familiar with the specifics of their dental insurance benefits. Your dental benefits are based on the agreement your employer negotiated with your insurance carrier. Please review the insurance benefit booklet provided by your employer to better understand the benefits they make available as part of your insurance coverage. The patient payment portion covered for procedures varies depending on the coverage provided by your employer.

An estimate of the amount covered by your insurance company will be provided at the time of your treatment, based on the information they provide to us. The estimate is never a guarantee of benefits or the amount that will be paid. We will file all insurance claims as a courtesy to our patients. This does not however, transfer the responsibility of your financial obligation to the insurance company. If the amount paid by the insurance company is less than or greater than the estimate, then you will be billed the difference or issued a credit on the account in the event of an over payment. Please let us know if you have questions about our financial policies or financing options prior to your treatment.

Cancellation Policy

Kindly provide at least 48 hours notice for any appointment that needs to be rescheduled. Appointments cancelled in less than 24 hours may be subject to a cancellation charge.

Discrimination Policy

Discrimination is Against the Law
David M. Wolf, DDS, PC complies with applicable Federal civil rights laws and does not discriminate on the basis of race,
color, national origin, age, disability, or sex.
David M. Wolf, DDS, PC does not exclude people or treat them differently because of race, color, national origin, age,
disability, or sex.

David M. Wolf, DDS, PC
• Provides free aids and services to people with disabilities to communicate effectively with us,
such as:
 ○ Qualified sign language interpreters
○ Written information in other formats (large print, audio, accessible electronic formats)
 • Provides free language services to people whose primary language is not English, click here for more information.
 ○ Qualified interpreters
 ○ Information written in other languages
If you need these services, contact David M. Wolf, DDS
If you believe that David M. Wolf, DDS, PC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the U.S. Department of
Health and Human Services, Office for Civil Rights, electronically through the Office for Civil
Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 

Privacy Policy

David M. Wolf, DDS, PC
37 Birch Street, Milford, MA 01757  / 508-473-4999 / www.davidwolfdds.com

Your Information. Your Rights. Our Responsibilities.
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.
Your Rights
You have the right to: 
Get a copy of your paper or electronic medical record
Correct your paper or electronic medical record
Request confidential communication
Ask us to limit the information we share
Get a list of those with whom we’ve shared your information
Get a copy of this privacy notice
Choose someone to act for you
File a complaint if you believe your privacy rights have been violated
Your Choices
You have some choices in the way that we use and share information as we: 
Tell family and friends about your condition
Provide disaster relief
Include you in a hospital directory
Provide mental health care
Market our services and sell your information
Raise funds
Our Uses and Disclosures
We may use and share your information as we: 
 Treat you
Run our organization
Bill for your services
Help with public health and safety issues
Do research
Comply with the law
Respond to organ and tissue donation requests
Work with a medical examiner or funeral director
Address workers’ compensation, law enforcement, and other government requests
Respond to lawsuits and legal actions
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. 
We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. 
We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
You can complain if you feel we have violated your rights by contacting us using the information on page 1.
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights 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 will not retaliate against you for filing a complaint.

Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
Share information with your family, close friends, or others involved in your care
Share information in a disaster relief situation
Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
Marketing purposes
Sale of your information
Most sharing of psychotherapy notes
In the case of fundraising:
We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures
How do we typically use or share your health information? 
We typically use or share your health information in the following ways.
Treat you
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services. 

Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities. 

Example: We give information about you to your health insurance plan so it will pay for your services. 

How else can we use or share your health information? 
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as: 
Preventing disease
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone’s health or safety
Do research
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
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.
Our Responsibilities
We are required by law to maintain the privacy and security of your protected health information. 
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it. 
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. 
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.

Other Instructions for Notice
Effective Date of this Notice 1/1/2018
Privacy official: David M. Wolf, DDS contact: david@davidwolfdds.com / 508-473-4999