Contact Us at Lakeville Dental Associates

We at Lakeville Dental 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 02/18/22, 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.

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 practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities.

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 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 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 a 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 lled prescriptions, medical supplies, X-rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing 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 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 serious threat 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 may disclose to authorized federal ocials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement ocial 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.

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:

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 or letters).

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. We will charge you a reasonable cost-based fee for expenses such as copies, mailing, and staff time. You may also request access by sending us a letter to the address 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).

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 Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

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 le a complaint with us or with the U.S. Department of Health and Human Services.

Thank you for choosing Lakeville Dental Associates as your dental healthcare provider. We are committed to providing you with the highest quality comprehensive dental care, so that you may attain optimum oral health. The following is our financial agreement which outlines your financial obligation to our practice. We require that you read, agree to, and sign prior to any treatment.
Payment is due at the time service is provided. Our office accepts cash, personal checks, credit cards and third party patient financing upon approval.

We are an unrestricted provider and can accept any insurance plan that allows you to choose your own dental provider. We are not contracted or in network with any insurance carrier.
If you have provided us with your dental insurance information, we will file your claim as a complimentary service for you. We will always work to help you maximize your benefits based on the information provided to us by your insurance company. Please know that the treatment our doctors recommend will be based on your individual needs, not your insurance coverage.
We are happy to provide you with an estimate of what your dental benefits may cover for recommended treatment. This estimate is based on information provided to us by your insurance company. This is not a guarantee of what will be covered by your insurance company. Your insurance company and plan benefits will ultimately determine coverage and the amount paid. We are happy to accept Assignment of Benefits whenever your benefit plan allows.
Assignment of benefits is plan specific and between you, your employer and your insurance company. If your plan allows assignment of benefits, Your deductible and co-payment, which is the estimated amount not covered by your benefit plan, are due on the day service is provided.
If your plan does not allow assignment of benefits, you are responsible for payment in full at the time service is provided. We will file the claim as a courtesy and your insurance company will reimburse you directly based on your dental benefit plan. We must emphasize that as your dental healthcare provider, our relationship is with you, our patient, not with your insurance carrier. Your insurance policy is a contract between you, your employer, and your insurance company. We will cooperate fully with any requests of your insurance company that may assist in the claim being paid. However, if your insurance company has not made payment within 60 days, you will be responsible for paying the full amount at that time. Our office will not enter into a dispute with your insurance company over any claim.

We are happy to help you review your dental benefits and answer any questions you may have; however, you are responsible for understanding your dental benefits.
You have ultimate financial responsibility for your account regardless of whether your insurance covers your treatment.

over 60 days old will be subject to a monthly interest of 0.5% (APR 6%). If necessary, unpaid accounts will be transferred to a collection agency.

We take great pride in being a small, locally owned, family-run dental practice dedicated to your oral health. Our goal is to build meaningful relationships with you and your loved ones while delivering the highest-quality personalized dental care.
Every appointment is exclusively reserved for your benefit, providing ample time for you to consult with our hygienists and doctors. To uphold our commitment to personalized care for all our patients, we kindly request your adherence to the following appointment agreement:

We greatly appreciate your cooperation and look forward to the opportunity to provide exceptional care for you and your family!