WHEN PATIENTS COME FIRST, EVERYONE WINS

New Patient 
Forms-Adult

We cannot wait to meet you!
Take a little time before your appointment with us to fill out these forms and email them to us at
    team@alluredentalhealth.com    

DOWNLOAD

Treatment
Consent

Congratulations! You have taken a huge step towards a beautiful and healthy smile. You are just one step closer to the smile of your dreams!

DOWNLOAD

New Patient Forms-Child

You can rest easy knowing that your child will enjoy every minute of their time with us! From Netflix to our Kid's zone, we have taken the steps to ensure their relaxation.

DOWNLOAD

WARNING:
SMALL BORING PRINT AHEAD...

Allure Dental Privacy Policy

Allure Dental is committed to preserving the privacy and confidentiality of your health information. This notice of privacy practices describes how we may use and disclose your health information, referred to as "PHI" to carry out treatment, payment or office procedures and for other purposes that are premitted or required by law. This notice is effective 12/19/2016. You may access or obtain a copy according to the following options: 1)Here on our website 2) Contact the office and request a copy be sent to you by mail or email 3) request a copy at your next appointment.
   
Get an electronic or paper copy of your medical/dental record: You can ask to see or get an electronic or paper copy of your PHI.  Ask us how to do this.  We will provide a copy or a summary of your health information within 30 days of your request.  We may charge a reasonable fee.

Ask us to amend your medical record: You have the right to request we amend your health information that you believe to be incomplete or incorrect.  We may deny your request, but we will provide you an explanation in writing within 60 days.

Request confidential communications: You can ask us to contact you in a specific way (for example, home, office or cell phone) or to send mail to a different address.  We will accommodate 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 office procedures.  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 healthcare 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 insurance provider.

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 PHI for six (6) years prior to the date you ask, who we shared it with and why.  We will include all disclosures except for those about treatment, payment and office procedures, and certain other disclosures (such as any you asked us to make).  We’ll provide one accounting a year for

free but may charge a reasonable fee if you ask for another one within twelve (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, that person can exercise your rights and make choices about your health information.  We will make sure that person has authority and can act for you before we take any action.

File a complaint: You can file a complaint if you feel we have violated your child’s rights by contacting:
                  Allure Dental
                  1901 Hwy 190
                  Suite 14
                  Mandeville, LA 70448
                  Ph: 985-951-2220
                  www.AllureDentalHealth.com

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. 20210, calling 877-696-6775, or visiting www.hhs.gov/ocr/privacy/hippa/complaints/.

We will not retaliate against you for filing a complaint.

In these cases, you have both the right and choice to:
Share information with your family, friends, or others involved in your care.
Share information in a disaster relief situation.
Contact you for fundraising efforts.

If you are unable to tell us your preferences, we may go ahead and share your information if we believe it’s 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

OTHER USES AND DISCLOSURES:  How do we typically use or share your PHI? We typically use or share PHI information in the following ways.

Treatment of your child.   We can use your PHI and share it with other professionals who are treating him/her.

Run our practice.  We can use and share your PHI to run our practice, improve your care and contact you when necessary.

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

How else can we use or share your PHI? 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/conconcon/index.html

Help with public health and safety issues.  We can share PHI 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 and preventing or reducing a serious threat to anyone’s health or safety.

Comply with the law.  We will share information about you if state or federal laws require it, including the Department of Health and Human Services if it wants to see that we’re complying with the federal privacy law.

Work with a medical examiner or funeral director.  We can share information with a coroner, medical examiner or funeral director when an individual dies.

Address law enforcement and other government requests.  We can use or share PHI for law enforcement purposes or with a law enforcement official, with health oversight agencies for activities authorized by law and for special government functions such as military, national security and presidential protective services.

Respond to lawsuits and legal actions.  We can share PHI 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 PHI.  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 PHI 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.

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.