THOMAS W. MABRY, D.D.S., P C
PRACTICE LIMITED M PER10WNTICS
AND DENTAL IMPLANTS
In order that you are not kept waiting, we reserve your appointment time for orlly you and do not
double book our appointments. This allows us to see you on schedule because we understand your time is
Payment is due when services are rendered. Master Card, Visa, personal checks and cash may be
used for any payment. On surgical and more involved procedures, we will be willing to accept insurance
payment on assignment when a pre-determination has been filed. It is our normal policy to accept
assignment from primary insurance only. Filing to your secondary insurance wil! be your responsibility.
We will be happy to assist you in filing your insurance claim, once you have provided us wilh
complete dental insurance information. This form must be signed to allow us to release the necessary
information and allow the insurance company to mail payments to our office. Please understand that
insurance contracts exist between the patient and the insurance company and not with Dr. Mabry. Dr.
Mabry is not a participating provider on any dental plan and it is ultimately the patient's responsibility
alone to insure payment to Dr. Mabry. Accounts with balances older than 60 days will be charged a
finance rate of 1.5% per month. Balances older than 90 days may be submitted to our agent or attorney for
Note: Medicare does not cover any procedures performed in this office. Medicare does not cover
deep scaling, root planing, osseous surgery or extraction.
NOTICE OF PRIVACY PRACTICES
I understand that my healthcare inforrnation concerning my diagnosis, treatment, payment, and
insurance will be disclosed when necessaiy for filing my insurance, and i communicating with other
health professionals in the course of my treatment at their offices. Limited information will also be
disclosed to businesses supporting the operations of this office such as dental or medical labs,
hospitals, accountant, computer support, billing personnel, answering services, dnd consultants. 'These
businesses are restricted in the use and disclosure of my information by contract. Disclosure may also
Occur for any necessary legal purposes or appropriate governmental authorities. If a family member or
person is paying for my healthcare with my knowledge, we may disclose information to that family
member or person;
I understand that my files m i stored on shelves in the business oftice. Only staff and janitorial
personoel may have access to this office during non-business hours. I undentand that this office will.
make every effort to keep my information secure and correct any violation of my privacy if this should
1 understand that I have the right to access, copy or inspect and correct my healthcare information, the
right to restrict disclosures and obtain an accounting of disclosures. I have the right to voice my
concerns about privacy to the practice andlor the Secretary of Health and Human Services within 180
days of my discovery of a disclosure violation without fear of retaliatory acts by this ofice. I may
correct my records in the form of a letter signed by me. I also have the right to revoke mjl- . .
authorization for disclosure. ( A minimal fee (20lpage) will. be charged to me for copies of records that
I request). '
1 2 4 1 -A 7TI-l STREEZ SLIDELL, LOUISIANA 70458 T M P H O N E (985)646-1 4 2 1
800 C.M.FAGAN DRIVE SUITE E HAMMOND, LOU18IANA 70403 TELEPHONE (988) 3 S G 1 4 4 4
1 understand that I will receive communication in the form of phone calls andlor postcards to remind
me of an existing appointment, or that it is time to schedule an appointment. I may receive mail
containing Cinancial information, such as ledgers or bills. ~ornhunicationmay also be sent to me in
the forms of fax or e-mails or other electronic,means. 1 understand that if a message is left For me 10
return a call, the message will contab the doctor's name and phone number. Complete messages
concerning my health information may be left on my personal home or work voice mail.
1 have reed and understand this office policy. I understand that by signing this aseement, I give my
permission for the use and disclosure of my personal and health information in order to cm-y out treatment,
payment activities, insurance claims, and healthcare operations. This office retains the right to revise the
Signahlre Date ,
0 I have read this form and do not wish to sign.