Patient Rights Policy

Patient Bill of Rights and Responsibilities

A Patient has the right to:

• Receive all necessary dental care that is available from our office or receive a referral to another provider.
• Considerate, courteous, quality care with respect for personal privacy and human dignity.
• Information concerning his/her diagnosis, treatment, and prognosis (i.e., clear concise communication from our staff, access to his/her medical records in compliance with the law).
• Involvement In the decision-making concerning his/her treatment (i.e., giving informed consent prior to treatment, right to refuse treatment to the extent permitted by law).
• Confidentiality of information concerning one’s treatment.
• File a grievance and be given due process.

If you are unable to resolve the issue with the Practice Manager, you may send a written grievance to:

Western New York Dental Group

Attn: Regional Director

2430 North Forest , Suite 210

Getzville, NY 14068

A Patient has the responsibility to:

• Comply with prescribed dental instructions from our office.
• Provide accurate past and present information to our office.
• Keep appointments for care and give required 48 hours’ notice to our office when canceling appointments.
• Maintain his/her health and participate in the decisions concerning treatment.
• Ask questions of the provider if he/she doesn’t understand.
• Make payments due for services received according to established terms.
• Inform his/her provider about any living will; medical power of attorney, and or other directive that could affect his/her care.

Western New York Dental Group (the “Practice”) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. The Practice does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. The Practice:

Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, please contact the office prior to your appointment. If you believe that the Practice has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance by mail :

Civil Rights Coordinator 2430 North Forest, Suite 210 , Getzville, NY 14068 You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at http://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, DC 20201 Toll Free: 1-800-868-1019 800 537-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Language Assistance Services – New York ATTENTION: If you speak a language listed below, language assistance services, free of charge, are available to you. languages CMS, Top 15 non-English Languages by State is available at: http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Appendix-A-Top-15.pdf Translated taglines available at: http://www.hhs.gov/civil-rights/for-individuals/section-1557/translated-resources/index.html