STEVEN J.FELDMAN,D.D.S., P.A.

236 Milan Avenue, West, Venice, Florida 34285
Phone: 941/485/9633 * Cell Phone: 941-724-9577 * Fax: 941/480-0808

NOTICE OF PRIVACY

This notice describes how your health information may be used and disclosed and how you can
access this information.Please review it carefully. EFFECTIVE AS OF APRIL 14, 2003.

At Steven J. Feldman, DDS we always keep your health information secure and confidential. A new law requires us to continue maintaining your privacy, to give you this notice and to follow the terms of this office.

Do we have your permission regarding.

Personal Health Information(PHI): / May we use or disclose your health information:

For treatment and service?

To your general dentist?

To a specialist?

Normal healthcare operations in our office?

Billing/Payment information (insurance)?

To Contact you, may we share information:

Answer machine/voice mail?

The person who answers your telephone?

Appoinment information?

With a family member or another person responsible for your care?

We will use whatever address or telephone number you prefer.

We may use or disclose your PHI without your permission:

In an emergency?

When required by law (such as abuse/neglect/accident)

You have the right:

  • To transfer copies of your personal health information to another practice.
  • To see and receive a copy of your personal health information.
  • To request amendment or change to your personal health information.
  • To receive a copy of this notice.
  • To request restrictions on how your personal health information is used and disclosed.
  • To an accounting of disclosure of those who received your PHI from us.
  • To complain or get more information.
  • You may file a complaint with the Department of Health and Human Services, 200 Independent Avenue, S.W. Room 509F, Washington, DC 20201, (877) 696-6775, toll free.
    However before filing a complaint, or for more information or assistance regarding your health information
    privacy, please contact our Privacy Officer, at (941) 485-9633.
I give permission to share health information with the person/persons listed below:

I give permission to share appointment information with the person/persons listed below:

If signing as a parent or guardian, please note the name of the patient

I also understand that by refusing to sign or revoking this consent/notice, Steven J. Feldman, D.D.S, P.A.
may refuse to treat me as permitted by Section 164.520 of the Code of Federal Regulations.

Patient Health Record

Medical Health

General health (please check)

Are you taking any medications now?

Have you ever been treated for:

Heart disease

Stroke

Abnormal blood pressure

Rheumatic fever

Heart murmur

Congenital heart lesions

Cardiac surgery

Anemia

Jaundice or liver disease

Hepatitis

Kidney disorders

Chemotherapy

Artificial heart valve

Artificial joint

Blood diseases

Blood transfusion

Osteoporosis

HIV/AIDS

Immune system deficiencies

Radiation treatments

Prolonged bleeding

Cancer

Diabetes

Glaucoma / EYE DISEASES

Lung disease or tuberculosis

Asthma or hayfever

Sinus trouble

Cough

Arthritis

Gastrointestinal disease

Ulcers

Epilepsy

Neurological disorder

Pacemaker

Have you had or do you have cold sores?

Have you had or do you have cold Herpes?

Alcohol

Are you allergic to:

Penicillin

Codeine

Local injected anesthetics

Other medications

Smoking?

How much?

How long?

Data stopped?

Are you presently under stress?

Are you Menopausal?

Are you Post menopausal?

Are you Under hormone therapy?

Are you pregnant?

Are you interested in learning about ways to improve your health easily by getting more fruits, vegetables and grains in your diet?

Gender

Patient Status

Dental Insurance

Payment Options

Payment in full is due the day of treatment. Financial options are:

  • Check
  • VISA
  • MasterCard
  • American Express
  • Discover

We also offer the option of Care Credit.

It is a financial arrangement between you, the patient, and Care Credit. It provides patients who qualify, a 24 month interest free payment plan. Dr. Feldman pays the interest. This often allows patients to begin their treatment quickly and more comfortably.

Shannon, our receptionist, can help you apply while at the office or you can apply online, www.carecredit.com or call 800.365.8295. It
has been a very successful option for many of our patients.

Participating Charities in Dr. Steven Feldman's Charitable Giving Campaign. You can either write a check or use a credit card and we will
mail it to the charity of your choice.

  • Boys and Girls Club of Venice
  • Tidewell Hospice
  • Salvation Army of Venice
  • All Children’s Hospital
  • Disabled Veterans – Local 101
  • The Sierra Foundation – Florida Chapter
Island Venice