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You Are Worth It!

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You Are Worth It! Congratulations! I am so happy that you’ve taken this important step and made the incredible decision to move forward with your treatment. The very reason I decided to limit my practice is to help patients with pain and sleep problems achieve true happiness, and I commend you for embracing the bright future you want. You are worth it! Coming from a family of physicians, I learned at a young age the importance and impact of good healthcare. Several years ago, I developed craniofacial pain and decided to learn more about treating it. During my learning process, I noticed in my specialty practice of Periodontics, Implantology and Endodontics, that many of my patients had similar problems. After treatment, several commented that their quality of life had improved. I developed a passion to help people suffering from a myriad of symptoms related to Sleep and TMJ Disorders. By treating these issues and helping patients achieve greater rest and pain free days, I’ve seen whole lives turn around. Now that is something to get excited about! It is heartbreaking to watch people delay the care they need, and that is why I am so impressed and inspired that you have selected to move forward with your treatment. Again, A HUGE CONGRATULATIONS to you for embracing life, and getting the world-class care you deserve. To maximize our time together, please complete the medical intake forms and return to our office 24 hours prior to your appointment. You can email them to [email protected] or fax to (972) 538-3751. We are about to take an amazing journey together, and I can promise you that the time you spend with us will be memorable, enjoyable and inspiring. You’ll be in the very best hands while you’re here, and I’m certain you are going to love the results. Sincerely, Dr. Shab Krish DDS, MS, DABCP, DABCDSM INSTRUCTIONS FOR YOUR APPOINTMENT MEDICATIONS: Please do not take any pain medications before your appointment to insure accurate testing for exam. CLOTHING/ MAKEUP: We will be taking diagnostic pictures and request that you wear short sleeved shirts and no collar. Long hair should be over ears and pulled back off neck and shoulders with nonmetal clips or bands. Jewelry and piercings will need to be removed from the neck and ears if possible. Please no heavy perfume or cologne. If you have any questions or concerns, please ask or call the office at 972-538-3777. We are here to help. What NOT to wear: What to wear: Long sleeve shirt Short sleeve shirt Hair down Hair pulled back Ears hidden Ears visible Jewelry/piercings No headband/clips Collared shirt No jewelry/piercings Heavy perfume No collar No heavy cologne/perfume NOTICE OF PRIVACY PRACTICES This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. We want you to know about the policies and procedures which we In Patient Reminders developed to make sure your health information will not be shared with Because regular care is very important in your treatment, we will remind anyone who does not require it. you of a scheduled appointment or that it is time for you to contact us and make an appointment. Additionally, we may contact you to Our office is subject to State and Federal law regarding the follow up on your care and inform you of treatment options or confidentiality of your health information and in keeping with these services that may be of interest to you. These communications are an laws, we want you to understand our procedures and your rights as our important part of our philosophy of partnering with our patients to valuable patient. ensure they receive the best quality care. We will use and communicate your HEAL TH INFORMATION only for Abuse or Neglect the purposes of providing your treatment, obtaining payment and We will notify government authorities if we believe a patient is the conducting health care operations. Your health information will not be victim of abuse, neglect or domestic violence. We will make this used for other purposes unless we have asked for and been voluntarily disclosure only when we are compelled by our ethical judgment, given your written permission. when we believe we are specifically required or authorized by law or with the patient’s agreement. HOW YOUR HEALTH INFORMATION MAY BE USED Public Health and National Security We may be required to disclose Federal officials or military authorities’ To Provide Treatment health information necessary to complete an investigation related We will use your HEALTH INFORMATION within our office to to public health or national security. Health information could be provide you with the best care possible. This may include administrative important when the government believes that the public safety could and clinical office procedures designed to optimize scheduling benefit when the information could lead to the control or prevention of and coordination of care between hygienist, dental assistant, dentist, an epidemic or the understanding of new side effects of a drug and business office staff. In addition, we may share your health treatment or medial device. information with physicians, referring dentists, clinical and dental laboratories, pharmacies or other health care personnel providing For Law Enforcement treatment. As permitted or required by State or Federal law, we may disclose your health information to a law enforcement official for certain law To Obtain Payment enforcement purposes, including, under certain limited circumstances, if We may include your health information with an invoice used to collect you are a victim of a crime or in order to report a crime. payment for treatment you receive in our office. We may do this with insurance forms filed for you in the mail or sent electronically. We Family, Friends and Caregivers will be sure to only work with companies with a similar commitment We may share your health information with those you tell us will be to the security of your health information. helping you with your treatment, medications or payments. We will be sure to ask your permission first. In the case of an emergency, To Conduct Health Care Operations where you are unable to tell us what you want we will use our Your health information may be used during performance very best judgment when sharing your health information only when evaluations of our staff. Some of our best teaching opportunities use it will be important to those participating in providing care. clinical situations, experienced by patients receiving care at our office. As a result, health information may be included in training Authorization to Use or Disclose Health Information Other than is stated programs for students, interns, associates, and business and clinical above or where Federal, State or Local law requires us, we will not employees. It is also possible that health information will be disclosed disclose your health information other than with your written during audits by insurance companies or government appointed authorization. You may revoke that authorization in writing at any time. agencies as part of their quality assurance and compliance reviews. Your health information may be reviewed during the routine processes of certification, licensing or credentialing activities. PATIENT RIGHTS This new law is careful to describe that you have the following rights Your request may be denied if the health information record in question related to your health information. was not created by our office, is not part of our records or if the records containing your health information are determined to be accurate and Restrictions complete. You have the right to request restrictions on certain uses and disclosures or your health information. Our office will make every effort to Documentation of Health Information honor reasonable restriction preferences from our patients. You have the right to ask us for a description of how and where your health information was used by our office for any reason other than Confidential Communications treat-ment, payment or health operations. Our documentation procedures You have the right to request that we communicate with you in a certain will enable us to provide information on health information usage from way. You may request that we only communicate your April 14, 2003 and forward. Please let us know in writing the health information privately with no other family members present or time period for which you are interested. Thank you for limiting your through mailed communications that are sealed. We will make every request to no more than six years at a time. We may need to effort to honor your reasonable requests for confidential charge you a reasonable fee for your request. communications. Inspect and Copy Your Health Information You have the right to read, review, and copy your health information, including your complete chart, x-rays and billing records. If you would like a copy of your health information, please let us know. We may need to charge you a reasonable fee to duplicate and assemble your copy. Amend Your Health Information You have the right to ask us to update or modify your record if you believe your health information records are incorrect or incomplete. We will be happy to accommodate you as long as our office maintains this information. In order to standardize our process, please provide us with your request in writing and describe your reason for the change. I have read, understand, agree and consent to following policies (Please initial each section and sign at the bottom of this page): Private Patient Agreement I am aware that Shab R. Krish, DDS, MS and the TMJ & Sleep Therapy Centre of North Texas are not contracted with my insurance company.
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