2335KNOBCREEKROAD，SUITElO7

JOHNSONCllYTENNESSEE37604（423）282－1030

FAX（423）282・4714

www．chadiohnsondds．com

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Date：

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CHADJOHNSON，D〟D。S．，P〟C・FAMILY＆COSME77CDEN77STRY

2335KnobCreekRoad，SuitelO7

Johns°nCity，TN37604

Teiephone：（423）282－1030

Fax：（423）282－4714

FINANCIALAGREEMENTPOLICY

Toreduceouradministrativecostsandkeepourfeestoyouaslowaspossible・WeaSkthatyoupay

foralIservicesrenderedatthedayofyourappointment・一fyouhavedentalinsurance・Pieasepay

your聾唖塑PerCentageatthetimeyoureceivetreatment・AnybaIanceover60daysw冊e

subjecttofinancechargesattherateofl・5％perm。nth・Returnedcheckfeeis＄25・00・

pleaseindicatebel0Wthemethodofpaymentyouintendtousetopayforyourdentaltreatment・

includingyourco－Payment・

PAYMENTOPTIONS

Cashorcheck

VisaorMasterCard

ElectronicFunds（DebitCard）

EXTENDEDPAYMENTOPTIONS

CareCredit（ApprovaiRequired）

APPOINTMENTCANCELATIONPOLICY

ourgoa－istohe－pyouachieveandmaintainahealthyandattractivesmile・lnordertoaccompIishthis・

itisimpohantthatyoukeeptheappointmentsreservedforyou一丁。betterSerVeOurPatientswerequlre

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MISSEDAPPOINTMENTPOLICY

1．FortheFIRSTmissedapp0両ment；（ina12monthperiod）wew冊rytoassistinrescheduIing

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oHicestressingtheimportanceofyourdenta－hea－thandthepotentialheaithreIated

consequencesfordelay－ngdenta－treatment・AIsoreinforc－ngOurmissedappo血mentpoiicy・

3．1faTHIRDmissedappointmentshou－doccurwithina12monthperiod）OurO冊cew冊Ot

reschedu－eyouforanotherappointment・Thismayresu－tindismissalfromthepractice・Wewiii

assesseachonacasebasedoncircumstances・

Amissedappointmentisanycance一一ationornoshowwithIessthan24hours’notice・

PrintNameofPatientorResponsible PaHy SignatureofPatientorResponsibIePahy

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MarketingHeam－RelatedServices：We画tinotuseyourheaIthinfomationformarketingcommunications

Withoutyourauthorization．

RequiredbyLaw：Wemayuseordiscioseyourhealthinfomationwhenwearerequiredtodosobylaw・

AbuseorNeglect：Wemaydiscloseyourheai廿日nformationtoapprOPriateauthoritiesifwereasonabIybeIieve

thatyouareapossibievictimofabuse，neglect，domesticvioience・Orthepossibievictimofothercrimes・Wemay

discIoseyourhealthinfomationtomeextentnecessarytoavehaseriousthreattoyourhea柵OrSafety・Orfor

thehealthorSafetyofothers．

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reminders（SuChasvoi∞mailmessages，teXtmeSSageS，e－maiI．Postcards，OrletterS）・

PatientRiqhts

Access：YouhavetherChtt0100katorget∞PleSOfyourhea剛infomation，Withlimitedex∞PtionsiYoumay

requestthatweprovide∞PleSinafomatotherPhoto∞P－eS・Wew川usethefomatyourequestunlesswe

cannotpracticabiydoso・Youmustmakearequestinw両ngt00btainaccesstoyourheaith而ormation・You

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aisorequestac∞SSbysendingusalettertotheaddressattheendof帥SNoti∞・WeMIlnotchargeyoufor

expensessuchascopleSandstafftime・Ifyouprefer，We面IIprepareasummaryoranexplanationofyourheaIth

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DisciosureAccounting：YouhavetherChttoreceiveaIistofinstancesinwhichweorourbusinessassociates

disciosedyourheaIthinformationforpurposes，OtherthantreatmentIPaymenthealthcareoperationsandcertain

otheractivitiesforthelast6years，butnotbeforeAp川14，2003・lfyourequestthisac∞untingmorethanoncein

a12－mOnthperiod，WemayChargeyouareasonable，COSt－basedfeeforrespondingtotheseadditionaIrequests・

AitemativeCommunication：Youhavetherighttorequestthatwe∞mmunicatewithyouaboutyourhea冊

informationbyaltemativemeansortoaltemativeIocations・YoumustmakevourreclueStinwrmnq・Yourrequest

mustspecifytheaItemativemeansorlocation，andprovidesatisfactoryexplanationofhowpaymentswilIbe

handIedundertheaItemativemeansorloc∈油onyourequest・

Res帥ction：YouhavetherighttorequestthatwepIaceadc囲0nairestrictionsonOuruSeOrdisciosureofyour

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Circumstances．

QuestionsandCompIaints

IfyouwantmoreinfomatbnaboutourpnVaCyPraCtCeSOrhavequestionsor∞n∞rnS・Please∞ntaCtuS・

Ifyouare∞nCemedthatwemayhavevioiatedyourprNacyrightsoryoudisagreew柵adecisionwemade

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Submitavt〃皿encomplaintotheU．S．Depa巾mentofhealthandHumanServices・We面目provideyouw冊十me

addressto刷eyour∞mPlaintwiththeU・S・DepammentofHea皿andHumanServi∞SuPOnrequeSt・

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軸ea∞mPIaintw肌usorwiththeU・S・DepartmentofHeaithandHumanServi∞S・

Contactinfomation：

ContactO冊cer：JessicaM00re

TeIephone：423T282－1030　Fax：423－282－4714

Address：2335KnobCreekRoad，Suite107．JohnsonCity，TN37604

C哩ohmson，D．D・S・，P・C・

Josh他言．ODeILD・D・S・

2335KnobCreekRoad，SuitelO7

JohnsonCity，TN37604

TeIephone：（423〉282－1030

Fax：〈423）282－4714

DisclosureofPatientinformation

Thispracticedisciosesinformationregardingyourtreatmentt00therhealthcareprofessionalsandinsurance

COmPanies，aSneededfortreatmentandforPaymentfortreatment・Ifinformationisrequestedbypersonsother

thanheaithcareprofessionaisandinsurancecompanies，thispracticew用onlydiscIosedentaitreatmenttothe

authorizedpersonsnamesbelow．Itisyourresponsib冊ytoinformusofanychangestothisinformation・

lglVePermissionforDr・JohnsonandDr・○）Deiland／OrhisempIoyeestodiscioseinforegardingtreatmenttothe

foIIowingperson（S）：

Name（PleasePrint）

Name（PleasePrint）

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Name〈PleasePrint）

Name（PIeasePrint）

Nameofpatient

SignatureofPatientorParentIGuardian

Reiationship

Relationship

ReIationship

ReIationship

ReIationship