Sinai OrthodonticsTERMS OF AGREEMENT
By submitting this referral form, you agree to the following terms and conditions for referring patients to Sinai Orthodontics:
1. REFERRAL PROCESS
The Referring Provider agrees to:
- Provide accurate and current contact information for both the referring provider and the patient
- Obtain patient's consent before sharing their information with the Practice
- Submit only essential information necessary for the referral process
- Maintain professional standards of care in the referral process
2. PRIVACY AND HIPAA COMPLIANCE
Both parties shall:
- Comply with all applicable HIPAA regulations and privacy laws
- Protect patient confidentiality and secure transmission of patient information
- Refrain from sharing Protected Health Information (PHI) through this initial referral form
- Use secure channels for subsequent transmission of detailed medical information
3. PATIENT CARE COORDINATION
The Practice commits to:
- Honor the specified service request (consultation, pre-treatment communication, or direct treatment)
- Maintain communication with the Referring Provider as indicated
- Provide appropriate updates regarding patient treatment progress
- Return the patient to the Referring Provider's care when orthodontic treatment is complete
4. PROFESSIONAL RESPONSIBILITY
Both parties acknowledge:
- Their respective roles and responsibilities in the patient's care
- The importance of clear communication regarding treatment plans
- The need to maintain accurate and complete patient records
- Their obligation to act in the best interest of the patient
5. LIABILITY AND INDEMNIFICATION
Each party shall:
- Maintain appropriate professional liability insurance
- Be responsible for their own acts and omissions
- Not hold the other party liable for treatment decisions made independently
6. TERMINATION
Either party may:
- Terminate the referral relationship with written notice
- Complete any ongoing patient treatment plans
- Ensure proper transfer of patient care when necessary
7. MODIFICATION OF TERMS
The Practice reserves the right to:
- Modify these terms with written notice to referring providers
- Update referral procedures as needed to comply with regulations
- Implement new protocols for patient care coordination
By checking "I Accept the Terms," you acknowledge that you have read, understood, and agree to these terms and conditions, and that you are authorized to make patient referrals to Sinai Orthodontics.