Schaun Chan Gabucan, Dmd
1535 Landess Ave. #142Milpitas, CA 95035
Phone: 408.945.8880 Fax: 408.945.8884
I understand that, under the Health Insurance Portability & Accountability Act 1996 (HIPAA). I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time 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 healthcare operations. I also understand you are not required to agree to my request restrictions, but if you do agree then you are bound to abide such restrictions.
I attempted to obtain the patient’s signature in acknowledgement on this NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT, but was unable to do so as documented below.
| Date | Initials | Reasons |
|---|---|---|
| 24-9-2025 | Initials | Lorem Ipsum is simply dummy text of the printing and typesetting industry. |
| 24-9-2025 | Initials | Lorem Ipsum is simply dummy text of the printing and typesetting industry. |
| 24-9-2025 | Initials | Lorem Ipsum is simply dummy text of the printing and typesetting industry. |
| 24-9-2025 | Initials | Lorem Ipsum is simply dummy text of the printing and typesetting industry. |
Schaun Chan Gabucan, Dmd
1535 Landess Ave. #142Milpitas, CA 95035
Phone: 408.945.8880 Fax: 408.945.8884
To accommodate patients’ demands all appointment changes must be done 48 hrs in advance. Unconfirmed appointments are considered confirmed. All cancellation and reschedule of Appointments within 24 hrs. will be billed for the time allotted. We understand that emergencies arise unexpectedly, and we will carefully assess each instance before applying any appointment fees. We reserve the right to charge $75 for occurred time allotted. ()
I, the undersigned, have read and understand the appointment policy. I agree to pay any charges, should I fail to keep an appointment.
As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their dental procedures. Financial responsibility of each patient must be determined before treatment. I certify that I and/or my dependent(s) have PPO Dental insurance coverage and assigned to Gabucan Family Dentistry all insurance benefits, if any, otherwise payable to me for services rendered at Gabucan Family Dentistry. I understand that I am financially responsible for all charges whether or not paid by insurance.
I authorize the use of my signature on all insurance submissions. Gabucan Family Dentistry may use my health care information and may disclose such information to the Insurance Company and their agents for purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. I grant my permission to Gabucan Family Dentistry staff or assignee to telephone me at home or at my work to discuss matters related to this form. I have read the above conditions of treatment and payment and agree to their content.
Schaun Chan Gabucan, Dmd
1535 Landess Ave. #142Milpitas, CA 95035
Phone: 408.945.8880 Fax: 408.945.8884
It is understood that any dispute as to dental malpractice, That is, as to whether any dental services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered will be determined by submission to arbitration as provided by California law, and not by lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.
A.Parties to the Agreement.The term “Patient” as used in this Agreement includes the undersigned individual, his or her spouse, Children (whether born or unborn), and heirs, assigns, or personal Representatives. The individual signing this Agreement signs it on Behalf of the foregoing persons, and intends to bind each of them to compulsory, binding arbitration.
D.Coverage of Prenatal Claims (If Applicable). Patient understands and agrees that, if Doctor treats her during pregnancy, and dispute of the sort described in Article I as to medical treatment rendered to or affecting the unborn child will be subject to compulsory, binding arbitration.
A.Informal Resolution of Dispute. In the event of Patient feels that the problem has arisen in connection with the medical care rendered by Doctor to Patient, Patient will promptly notify Doctor so that Doctor may have the opportunity to resolve the matter. Notice may be given orally or in writing, and shall stop the running of the statute of limitations for 90 days.
B.Method of Initiating Arbitration. If the dispute is not resolved by mutual agreement within 90 days. Patient may initiate arbitration by notifying Doctor to the effect and by designating an arbitrator to act on Patient’s behalf. Within 20 days of receipt of such notice, Doctor will designate an arbitrator to act on Doctor’s behalf. In the event that more than two parties participate, parties aligned with patient shall select one arbitrator, and parties aligned with Doctor shall select a second arbitrator. The two Arbitration to the full extent permitted by law. The term “Doctor” as used in this Agreement includes the undersigned doctor and his or her professional corporation or Partnership, and any employees, agents, successors-in-interest, Heirs, and assigns of the foregoing individuals or entities. The Doctor signing this Agreement signs it on behalf of all the foregoing individuals and entities, intends to bind each of them to arbitration to the full extent permitted by law.
B.Treatment Covered.Patients understands and agrees that any Dispute of the sort described in Article I between Doctor and Patient will be subjected to compulsory, binding arbitration.
C. Other Doctors (If Applicable). Patient understands that he or she may at any times receive treatment form one or more doctors who practice jointly with the undersigned doctor. It is understood and agreed that any dispute of the sort described in Article I between Patient and such Doctors practicing with the undersigned doctor will be subject to “party” arbitrators shall select a neutral arbitrator. The controversy shall then be submitted to the three arbitrators for a final and binding decision.
C. Applicable Law. The arbitration shall be conducted pursuant to the California Arbitration Act (C.C.P. 1290-1296). The arbitrators shall, in addition, have authority to the order such other discover as they deem appropriate for a full and fair hearing of the case. A determination on the merits shall be rendered in accordance with the law of the State of California including the provisions of the Medical Injury Compensation Reform Act of 1975 which shall apply to the same extent as if the dispute were pending before a superior court of this State.
D.Interpretation of Agreement. Any controversy concerning the interpretation or application of this Agreement itself shall also be submitted to arbitration in the manner provided above.
Revocation. If you sign this Agreement and then change your mind, the law permits you to revoke the Agreement, providing you give your Doctor written notice within 30 days from signing that you want to withdraw from the Agreement. However, Doctor and Patient agree that any claim arising from dental services rendered prior to the revocation shall be subject to arbitration.