CONTACTS
SUBJECTS
Dental Examination 2nd Opinion Dental Oral Health Requirements Optio
1703 -
1703 - ..
1704 - Summary/Objective
1705 -
170501 - Follow up ref SDS 43 0000. ref SDS 40 0000.
170502 -
170503 -
170504 -
170505 -
170506 - [On 141015 1327 received letter from Graham Dental offices
170507 - confirming meeting on 141021. ref SDS 47 0S51
170508 -
170509 -
170510 -
170511 -
170513 - ..
1706 -
1707 -
1708 - Progress
1709 -
170901 - Schedule Dental Review Kathy Periodontal Proposal for 1 Implant
170902 -
170903 - Follow up ref SDS 43 004T, ref SDS 40 004T.
170904 -
170905 - Next meeting on 141021, was scheduled in the medical chart received
170906 - with Doctor Mark Graham's letter on 140416 0800. ref SDS 43 6Z6Q
170908 - ..
170909 - Instead of doing another cleaning, would like to use this time for 2nd
170910 - opinion review of Kathy's condition, similar to review Doctor Graham
170911 - did on tooth #2 on 090302 0815. ref SDS 9 IS9O
170913 - ..
170914 - On 130826, Kathy met with her dentist for preparing a mold to make a
170915 - temporary tooth. It will be used to replace a failed implant
170916 - constructed about 10 years ago, and which had been removed by the
170917 - periodontist days earlier, what at that time, the periodontist also
170918 - performed initial bone graft remedial work to prepare for constructing
170919 - a new implant. ref SDS 39 6U5I
170921 - ..
170922 - The failed implant is one of 2 implants Kathy had done 10 years ago.
170923 - The other implant has not failed, so only 1 implant has to be replaced
170924 - at this time. The periodontist attributes failed implant to bone
170925 - loss, possibly related to smoking, reported on 130826 1733.
170926 - ref SDS 39 6U67
170928 - ..
170929 - Questions to review in second opinion based on Periodontist's
170930 - Treatment Plan (shown below, ref SDS 0 E64K, requiring the patient
170931 - sign acknowledgement that such issues have been "discussed" with the
170932 - dentist, per below. ref SDS 0 PSWQ
170933 -
170934 - 1. Perform implant per Periodontist's Treatment Plan dated
170935 - 140403, see below. ref SDS 0 E64K
170937 - ..
170938 - Can new implant failure recur in another few years, based
170939 - on evident weakness of jaw bone?
170941 - ..
170942 - Xrays of failed implant taken by periodontist; one taken
170943 - last year on 131001, and a 2nd xray taken this year on
170944 - 140408...
170948 - ..
170949 - 2. Construct a bridge instead of the implant.
170950 -
170951 - Can this cause damage to adjacent teeth? Will it last as
170952 - long as the implant?
170954 - ..
170955 - 3. Continue existing temporary filler component and forego
170956 - implant and bridge solutions.
170958 - ..
170959 - Will this cause further bone loss in the jaw, or any other
170960 - problems?
170962 - ..
170963 - Are there other risks of foregoing implant repair at this
170964 - time?
170966 - ..
170967 - 4. Other options and issues presented on 2nd opinion dental
170968 - examination
170969 -
170971 - ..
170972 - Called Kathy.
170974 - ..
170975 - She has a letter from the Periodontist, and will submit for
170976 - transmission with the agenda on meeting with Doctor Graham on 141021.
170977 -
170978 -
170980 - ..
1710 -
1711 -
1712 - 1340
1713 -
171301 - Called Lynn at Doctor Graham's office.
171302 -
171303 - She advised that I am scheduled for 0800 - 0900. Kathy is scheduled
171304 - for 0945, after another patient at 0900.
171305 -
171306 - [On 141015 1327 received letter from Graham Dental offices
171307 - confirming meeting on 141021. ref SDS 47 0S51
171309 - ..
171310 - Lynn put me on hold.
171311 -
171313 - ..
1714 -
1715 -
1716 - 1343
1717 -
171701 - Lynn came back online.
171702 -
171703 - She advised that the other patient agreed to switch places with Kathy,
171704 - so that Doctor Graham can see Kathy after he sees me.
171705 -
171706 - [On 141015 1327 received letter from Graham Dental offices
171707 - confirming meeting on 141021. ref SDS 47 0S51
171708 -
171710 - ..
1718 -
1719 -
1720 - 2140
1721 -
172101 - Received letter via electronic mail from Kathy transmitting the
172102 - periodontist's proposal dated 140403, for services to replace a dental
172103 - implant.
172105 - ..
172106 - The proposal is presented in 3 files in PDF format, one for each page
172107 - of the proposal. Tried using OCR tools to convert these PDF files
172108 - into text for efficient case management in the record. The OCR tools
172109 - are part of HP printer "Solution Center" configured with c17 on 110104
172110 - 0721. ref SDS 24 4S7K However today, could not find the HP Solution
172111 - Center nor other OCR tools for converting the PDF file into useful
172112 - text, reported several later on 141010 1228, ref SDS 45 RH3N
172114 - ..
172115 - A few days later, eventually, got printer configured to support
172116 - scanning, reported on 141013 0856, ref SDS 46 T465, and then was able
172117 - to scan PDF documents on Kathy's dental issues, into text for
172118 - notifying Doctor Graham to prepare for 2nd opinion meeting scheduled
172119 - on 141021.
172121 - ..
172122 - Turned out however, that scanned files are more of a jumble and take
172123 - longer to format in the record, than simply entering the text
172124 - manually, also reported on 141013 0856. ref SDS 46 QW7K
172126 - ..
172127 - Therefore, entered in the record below, documents on pending proposal
172128 - dated 140403, for periodontal work. ref SDS 0 E64K
172130 - ..
172131 - Proposal dated 140403 shows total cost of work - $3364; and, it
172132 - expired on 140708. ref SDS 0 C43G
172134 - ..
172135 - The proposal says in part...
172136 -
172137 - Patient Copays are DUE at the 1st appointment and/or pre
172138 - surgical appointments. ref SDS 0 C28F
172140 - ..
172141 - If the patient is paying the entire bill, does this mean payment is
172142 - required in advance of doing any work?
172144 - ..
172145 - A few days later, Kathy seemed to say that she expects to pay the
172146 - entire bill in advance.
172148 - ..
172149 - Proposal further says in part...
172150 -
172151 - I, the undersigned patient, understand my dental condition
172152 - and have discussed several treatment options with the
172153 - undersigned provider. ref SDS 0 C290
172155 - ..
172156 - Where is the record of "dental condition," "treatment options," and
172157 - any "discussion" with the periodontist and with the primary dentist?
172159 - ..
172160 - What do progress notes say on patient encounters?
172162 - ..
172163 - Some questions are listed above. ref SDS 0 SX6M
172165 - ..
172166 - Proposal further says in part...
172167 -
172168 - I understand the risks inherent in the treatment(s). I
172169 - have discussed these risks with the dentist. The dentist
172170 - has addressed all quetions and concerns I have presented.
172171 - ref SDS 0 PSWQ
172173 - ..
172174 - What does the record show for "risks inherent in the treatment(s) that
172175 - have been presented to the patient?
172177 - ..
172178 - Proposal further says in part...
172179 -
172180 - I understand the expected results of the procedure(s) or
172181 - course(s) of treatment. I understand that these results
172182 - cannot be guaranteed and may not be achieved. I am aware
172183 - of my right to waive treatment of any kind and I am aware
172184 - of the possible consequences of non-treatment. ref SDS 0
172185 - PSWQ
172187 - ..
172188 - What "results" of the implant procedure have been presented to the
172189 - patient?
172191 - ..
172192 - What are the chances of failing to achieve results of procedure?
172194 - ..
172195 - What are the consequences of non-treatment?
172196 -
172197 -
172198 -
172200 - ..
172201 - Periodontal Proposal Replace 1 Implant 7 Visits $3,364
172202 -
172203 -
172204 - 1. Mark H Zablotsky, DDS
172205 - #1 Scripps Drive Suite 305
172206 - Sacramento, CA 95825
172207 - 916 641 1200
172208 -
172209 - http:\\http://www.perioimplant.com
172211 - ..
172212 - 2. Patient:
172217 - ..
172218 - 3. Treatment Case
172220 - ..
172221 - 4. Treatment Plan 1
172223 - ..
172224 - 5. Date......................................... 2014 04 03
172226 - ..
172227 - 6. Case Notes:
172229 - ..
172230 - 7. Dental Implant Crowns are Restored at your General Dentist's
172231 - Office and All Fees are to be Discussed at Their Office.
172232 -
172233 - 1. Additional Fees may apply at our office prior to releasing
172234 - you to be restored, $35 - $100 for each implant...
172236 - ..
172237 - We dispense dental implant crown impression parts needed by
172238 - your restoring Dentist (an implant replica, impression
172239 - coping).
172241 - ..
172242 - 2. Recommend returning for final Post-op after General Dentist
172243 - has completed the final restoration to evaluate it and the
172244 - dental implant to inform you of proper home care needs. We
172245 - also recommend returning once a year depending on your
172246 - periodontal needs either an exam or hygiene visit. We like
172247 - to check dental implants on a yearly basis.
172249 - ..
172250 - 3. Once treatment is complete, we will submit claims to your
172251 - insurance company with the information you have provided
172252 - us. After 60 days, if insurance has not paid, you are
172253 - responsible for the balance on your account.
172255 - ..
172256 - 8. Patient Copays are DUE at the 1st appointment and/or pre
172257 - surgical appointments.
172259 - ..
172260 - 9. Estimated patient portion: $1,479 - $2,279 (if dental
172261 - benefits are available).
172263 - ..
172264 - 10. Treatment Plan Financial Estimate
172265 -
172266 - 1. I, the undersigned patient, understand my dental condition
172267 - and have discussed several treatment options with the
172268 - undersigned provider. I have been given a printed copy of
172269 - the procedure or treatment details and any post-op
172270 - instructions. We recommend non-strenuous activity for at
172271 - least 3 days post surgery to avoid complications. We also
172272 - recommend avoiding airplane travel for at least 1 week
172273 - after surgical procedures.
172275 - ..
172276 - 2. I understand the risks inherent in the treatment(s). I
172277 - have discussed these risks with the dentist. The dentist
172278 - has addressed all quetions and concerns I have presented.
172279 - I understand the expected results of the procedure(s) or
172280 - course(s) of treatment. I understand that these results
172281 - cannot be guaranteed and may not be achieved. I am aware
172282 - of my right to waive treatment of any kind and I am aware
172283 - of the possible consequences of non-treatment.
172285 - ..
172286 - 3. I have disclosed my health history information, including
172287 - allergies, reactions to medicine, diseases, and past
172288 - procedures. I understand that withholding this information
172289 - may affect the outcome of the procedure(s) or course(s) of
172290 - treatment.
172292 - ..
172293 - 4. I have discussed payment options and agreed upon a payment
172294 - plan with the insurance company and with the undersigned
172295 - provider. The treatment plan and fees are valid for 90
172296 - days. Once treatment is complete, we will submit claims to
172297 - your insurance comapny with the information you have
172298 - provided us. After 60 days, if insurance has not paid, you
172299 - are responsible for the balance on your account.
172301 - ..
172302 - 5. I confirm that I understand this form and the information
172303 - contained therein. I am a native speaker of English or
172304 - have been offred the services of a qualified translator who
172305 - has explained the information in my native tongue.
172307 - ..
172308 - 6. Code Description Fee
172309 -
172310 - D4381 Local deliv antmicrb ag-th B/R [6 D]......... 50
172311 - 04999 Perioscopy [UR].............................. 200
172312 - D4342 Perio scales&root pin 1-3th, quad [UR]....... 219
172313 - D017 Implant pre-op [moutn]....................... 0
172314 - D00 Re-eval [mouth].............................. 0
172315 - D0220 Intraoral periapical-1st film [5]............ 38
172316 - D7210 Extraction-surgical/erupt tooth [5].......... 357
172317 - D7953 Bone repl grft ridge prsv/site [5]........... 900
172318 - 01010 Implant set-up [6]........................... 375
172319 - D0220 Intraoral periapical-1st film [6]............ 38
172320 - D6010 Implant cylinder [6]......................... 2,018
172321 - D7953 Bone repl grft ridge prsv/site [6]........... 800
172322 - D004 Post op visit 1 [mouth]...................... 0
172323 - D004 Post op visit 1 [mouth]...................... 0
172324 - D007 PT2D (Polish) [mouth]........................ 0
172325 - D007 PT2D (Polish) [mouth]........................ 0
172326 - D005 Post op DR CK [mouth]........................ 0
172327 - D0230 Intraoral periapical-each addl [6]........... 38
172328 - D0009 Uncover implant [6].......................... 0
172329 - D005 Post op DR CK [mouth]........................ 0
172330 - 8882 Nobel restorative parts [6].................. 95
172331 - D4342 Perio scales&root pin 1-3th, quad [UR]....... 215
172332 - D005 Post op DR CK [mouth]........................ 0
172333 -
172335 - ..
172336 - 11. Signature
172338 - ..
172339 - 12. Date
172340 -
172341 -
172343 - ..
172344 - 13. Mark H Zablotsky, DDS
172345 - #1 Scripps Drive Suite 305
172346 - Sacramento, CA 95825
172347 - 916 641 1200
172348 -
172349 - http:\\http://www.perioimplant.com
172350 -
172352 - ..
172353 - 14. Name:
172357 - ..
172358 - Birthdate: 05\06\1949
172360 - ..
172361 - 15. Treatment Case
172363 - ..
172364 - 16. Treatment Plan 1
172366 - ..
172367 - 17. Visit TH Description Fee Totals
172368 -
172369 - 1 Implant pre op.............................. 0
172370 -
172371 -
172372 - 1............................................................ 0
172373 -
172374 -
172375 - 2 6 Implant set up.............................. 375
172376 - 2 6 Inraoral periapical-1st film .............. 38
172377 - 2 6 Implant cylinder........................... 2,018
172378 - 2 6 Bone repl grft ridge prsv/site............. 800
172379 - Notes: Fee $0 - 800
172380 -
172381 - 2............................................................ 3,321
172382 -
172383 -
172384 - 3 Post op visit 1............................ 0
172385 -
172386 - 3............................................................ 0
172387 -
172388 -
172389 - 4 PT2D (Polish).............................. 0
172390 -
172391 - 4............................................................ 0
172392 -
172393 -
172394 - 5 Post op DR CK.............................. 0
172395 - 5 6 Intraoral periapical-each addl............. 38
172396 -
172397 - 5............................................................ 38
172398 -
172399 -
172400 - 6 6 Uncover implant............................ 0
172401 -
172402 - 6............................................................ 0
172403 -
172404 -
172405 - 7 Post op DR CK.............................. 0
172406 - 7 6 Nobel restorative parts.................... 95
172407 -
172408 - 7............................................................ 95
172410 - ..
172411 - 18. Treatment Plan 1 Total.......................................... 3,364
172413 - ..
172414 - 19. Fee Expiration Date 2014-07-08
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1725 -