APPENDIX D - Notice Concerning Credit or Loan for Healthcare Services California Dental Practice Act, California Business and Professional Code, 654.3 Credit or Loan for Health Care Services The attached application and information are for a credit card or loan to help you pay for your health care treatment. You should know that: You are applying for a ________________________ credit card or a ____________________________ loan for $______________. You do not have to apply for the credit card or the loan. You may request a different place and additional time to review, fill out, and sign the application. You may pay your health care provider for treatment in another manner. This credit card or loan is not a payment plan with the provider’s office. It is credit with, or a loan made by, [name of company issuing the credit card or loan]. Your health care provider does not work for this company. Before applying for this credit card or loan, you have the right to a written treatment plan from your health care provider. This plan must include the expected treatment to be provided and the estimated costs of each service. If you have insurance, the treatment plan must tell you how much your insurance is expected to cover. If you are a Medi-Cal patient seeking services from a Medi-Cal provider, your treatment plan must tell you if Medi-Cal will cover a different service to treat your condition. If you only want services covered by Medi-Cal, you should not sign up for this credit card or loan. Your health care provider cannot charge your credit card or loan account before you start treatment. You have the right to have your credit card or loan account refunded for any charges for treatment you did not get. However, your provider does not have to refund the amount they spent to prepare for your treatment. Your health care provider must refund the amount of the charges to the lender within 15 business days of your request. The lender must take refunded charges off your account. Please read carefully the terms and conditions of this credit card or loan. You may be required to pay interest rates on the amount charged to the credit card or the amount of the loan. If you pay late, you may have to pay a penalty and a higher interest rate. You may use this credit card or loan to pay for future health care services. If you do not pay the money that you owe on the credit card or loan, your missed payments can be reported and could hurt your credit rating. You could also be sued. ________________________________________________________ [Patient’s Signature] Note. From California Dental Practice Act, California Business and Professional Code, 654.3. Note that the actual form needs to be set in 14-point type and fit on one page . APPENDIX E - Notice to Patients Poster WARNING Certain dental procedures performed in this office can expose you to chemicals known to the State of California to cause cancer or birth defects or other reproductive harm or both. Those procedures can include sedation with nitrous oxide, root canals, placement or removal of crowns, bridges, and restorations such as mercury-containing fillings and use of dental appliances. Consult your dental care provider about these exposures and which materials are appropriate for your treatment. Additional information is also available at www.P65Warnings.ca.gov/dental. APPENDIX F - Notice to Patients Poster - Dentists NOTICE Dentists are licensed and regulated by the Dental Board of California
(877) 729-7789 www.dbc.ca.gov APPENDIX G - Notice to Patients Poster - Hygienists NOTIFICATION TO CONSUMERS Dental hygienists are licensed and regulated by The Dental Hygiene Board of California (916) 263-1978 www.dhbc.ca.gov
WORKS CITED https://qr2.mobi/CA-dentalact7
EliteLearning.com/Dental
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