Office Payment Policy:
Notice of Privacy Practices Acknowledgement:
As a service and courtesy to our patients, we will be glad to file an insurance claim for you if you have current dental insurance. We expect payment of your anticipated portion at the time of service. If this amount is not paid, finance charges will begin after 30 days.
Please be aware that there is a $55.00 charge for missing any appointments without 24 hour notice.  
I hereby agree that in the event of non-payment I will be held liable for collection costs, including but not limited to: collection agency fees, reasonable attorney fees (which you expressly agree that the reasonable attorney fees shall be the greater of: (1) 50% of the unpaid balance; or (2) $400.00), court costs and interest at a rate of 18% per year, calculated daily, beginning from the last date of service or the last payment date. Unpaid balances shall also be subject to a data transfer of derogatory information about any unpaid balance to one, or all, of the three major credit bureau reporting agencies (Experian, Equifax or Trans Union). By signing below, I expressly authorize any collection agency or attorney involved in the collection of a debt owed by me to not only transmit this information but also to request a copy of your personal credit report (or credit profile) from one or more of the above referenced credit reporting agencies. ***There is a $30.00 charge for any returned checks. 
________________                ________________
Signature of Parent                Date
(Please sign and bring to office after reading Notice of Privacy Practices)
Jennifer R. Kugar, DDS, MSD 11501 Cumberland Road, Suite 600
Fishers, Indiana 46037
This notice describes how medical/dental information about you may be used and disclosed and how you can get access to this information.
The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.
As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.
We may use and disclose your health information/records only for each of the following purposes: treatment, payment, andhealth care operations.
Treatment means providing, coordination, or managing dental care and related services by one or more health care providers. Examples would include teeth cleaning/fluoride services, major restorative services, or referral to an oral surgeon or other dental specialist.
Payment means such activities as obtaining reimbursement for services, confirming coverage, bill or collection activities, and utilization review. An example of this would be submitting a claim to your insurance company for payment.
Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.
This practice will contact you by phone and mail to provide appointment reminders, information about treatment alternatives, billing activities or other health-related benefits and services that may be of interest to you.
We may also create and distribute de-identified health information by removing all references to individually identifiable information.
Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.
  • You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to our office:
  • The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
  • The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
  • The right to inspect and copy your protected health information.
  • The right to receive an accounting of disclosures of protected health information.
  • The right to obtain and we have the obligation to provide to you a paper copy of this notice from us at your first service delivery date.
  • The right to provide and we are obligated to receive a written acknowledgment that you have received a copy of our Notice of Privacy Practices.
We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health.
This notice is effective as of January 1, 2003 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.
You have recourse if you feel that your privacy protections have been violated. You have the right to file a formal, written complaint with us at the address below, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.
Please contact us for more information:
Jennifer R. Kugar, DDS, MSD
11501 Cumberland Road
Fishers, Indiana 46037
(317) 585-8055
For more information about HIPPA or to file a complaint:
The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Ave., S.W.
Washington, D.C.20201
(202) 619-0257 or Toll Free 1-877-696-6775
Notice of Privacy Practices Acknowledgement