Practice Limited to Periodontics and Implant Dentistry
Angela M. Miele, D.M.D., P.C.
Deborah A. Odell, D.D.S.
Di Umoh, D.D.S., M.S.
Liz Polak, D.M.D., M.S.
888 Bestgate Rd., Suite #300
Annapolis, MD 21401
Office #: 410-224-0500 Fax #: 410-224-6039
Acknowledgement Of Privacy Practices
My Signature confirms that I have been informed of my rights to privacy regarding my protected health
information, under the Heath Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that
this information can and will be used to:
- Provide and coordinate my treatment among a number of health care providers who may be
involved in that treatment directly and indirectly.
- Obtain payment from third-party payers for my health care services
- Conduct normal health care operations such as quality assessment and improvement activities.
I have been informed of my dental provider’s Notice of Privacy Practices containing a more complete
description of the uses and disclosures of my protected health information. I have been given the right to review
and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to
change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current
copy of the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to
carry out treatment, payment, or health care operations and I understand that you are not required to agree to my
requested restrictions, but if you do agree, then you are bound to abide to such restrictions.
For Office Use Only:
We were unable to obtain the patient’s written acknowledgement of our Notice of Privacy Practices due to the
- The patient refused to sign
- Communication Barriers
- Emergency Situation
- Other _______
1. Cancellation / No Show Policy for Doctor Appointment $75.00
We understand that there are times when you must miss an appointment due to emergencies or
obligations for work or family. However, if an appointment is not cancelled at least 48 business hours in
advance you will be charged a seventy five dollar ($75) fee for a missed hygiene visit.
2. Cancellation / No Show Policy for Surgery $250.00
If surgery is not cancelled at least three (3) business days in advance, you will be charged a fee
of $250. This is NOT covered by your insurance company.
3. Account Balances
Patients with self pay balances are required to pay their account balances to zero (0) prior to
receiving further services by our practice. Patients are encouraged to put a credit card on file for these
Patients who have questions about their bills or who would like to discuss a payment plan option
may call and ask to speak to an office manager with whom they can review their account and concerns.
Patients with balances over $100 must make payment arrangements prior to future appointments