H&L Dentistry Policy

Payment Options

Payment is due at the time service is rendered. If you have dental insurance, it is a contract between you and your insurance company. Benefit coverage is determined mostly by the employer providing the insurance. Expected insurance payments are an estimate until actual payment is received.  You are ultimately responsible for full payment of services rendered. 

For your convenience we accept cash, checks, Visa, MasterCard, American Express, Discover, Apple Pay and Android Pay.

We will assist you with filing dental insurance claims. Please visit our Insurance page for more information.


If you have dental insurance, please understand that insurance is an agreement between you and your insurance company. The patient (or the responsible party in case of minors) is fully responsible for the full payment of all services rendered.

Most insurance company’s fee schedules are different from actual fee schedules in a dental office. As a result, there is frequently a remaining balance due after your insurance company provides your benefit. We will estimate, to the best of our ability, this difference and ask for this payment at the time services are rendered. Any remaining balance after the insurance company has paid your benefit will be your responsibility. We cannot guarantee that any coverage estimated by your plan will be paid once a claim is filed. If your insurance company fails to release your benefit within 45 days of the treatment rendered, all balances will be due from you or the guarantor responsible for your account. If insurance benefits are paid directly to the policyholder, payment is due in full at the time of service. Checks that are returned to our office from your financial institution are subject to a returned check fee of $25.00. This fee covers the processing fees that are charged to our office.

We will charge a $50 collection agency fee to your account in the event that we require to use that service to collect your payments.




Hernandez & Lasanta PLLC (dba H&L Dentistry) is required by applicable federal and state laws to maintain the privacy of your health information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice went into effect February 15th, 2019 and will remain in effect until modified or replaced. We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all health information that we maintain, including health information we created or received before we made the changes. You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us.


We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

1. Treatment; We may use or disclose your health information to a physician/dentist, dental auxiliaries and other healthcare providers providing treatment to you.
2. Payment; We may use and disclose your health information to obtain payment for services we provide to you. When you pay, your credit card information is encrypted and protected in our merchant services (credit card processing system) and not sold to third parties.
3. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations ; include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performances, conducting training programs, accreditation, certification, licensing or credentialing activities.
4. Your Authorization In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this notice.
5. To Your Family and Friends We must disclose your health information to you, as described in the Patient Rights section of this notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so in writing. You can fill a form authorizing who you want your information shared with and to what extent. You can revoke this at any time by requesting it in writing to our office.
6. Persons Involved in Care We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up prescriptions, dental supplies, X-rays, or other similar forms of health information.
7. Contacting You We may use and disclose your health information to contact you about appointments and other matters, and to send you electronic billing statements. We may contact you by telephone, text (if requested), e-mail, or mail. We may leave you messages at the telephone number you give us. Communication containing PHI (protected health information) sent through our e- mails will be encrypted for your protection in accordance with the law. By requesting we communicate with you by text messaging we understand you agree with the following; text messages may not be encrypted (secure) and it may be possible for third parties to see your information. For your protection, we will limit the content shared in this manner. You may opt out of text communications my notifying us at any time. By engaging us in a text communication we understand you prefer or authorize this method and agree with its use.
8. Marketing Health-Related Services: We may use patient information to contact you to inquire or survey about the Patient experience at the office. We may utilize one or more third-party service providers to send email or other communications to you on our behalf, including Patient satisfaction surveys. These service providers are prohibited from using your email address or other contact information for any purpose other than to send communications on our behalf. It is our intention to only send email communications that would be useful to you and that you want to receive. When you provide us with your email address as part of the registration or appointment setting process, we will place you on our list of patients to receive informational and promotional emails. Each time you receive a promotional email or text message, you will be provided the choice opt out of future emails or texts by following the instructions provided in the email or text, or you can “opt-out†at any time by following the instructions provided.
9. REQUIRED BY LAW We may use or disclose your health information when we are required to do so by law.
10. Abuse or Neglect. We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect or domestic violence, or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety, or the health or safety of others.
11. National Security We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose, to authorized federal officials, health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to a correctional institution or law enforcement official having lawful custody of protected health information of an inmate or patient under certain circumstances.
12. Appointment Reminders; We may use or disclose your health information to provide you with appointment reminders (such as text messages, e-mails, voicemail messages, postcards, or letters).


Access You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. We may charge a fee for producing dental records and X-rays as allowed by law.

Disclosure Accounting You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations and certain other activities. We may charge you a reasonable, cost-based fee for responding to these additional requests.

You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). When you pay in full outside of your insurance plan for services you may request that we restrict this information and not disclose it to your healthcare plan or insurer.
Breach Notification We take all reasonable measures to avoid any type of breach. However, if a breach occurs, we will provide you with notification of a breach of unsecured PHI as required by law.
Alternative Communication You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. This request must be in writing. Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request.
Amendment You have the right to request that we amend your health information. This request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.

Electronic Notice If you received this notice on our web site or by electronic mail (e-mail), you are also entitled to receive this notice in written form.

Questions and Concerns If you want more information about our privacy practices or have questions or concerns, please contact our office.


You have the responsibility to provide, to the best of your ability, accurate, honest and complete information about your medical history and current health status.You have the responsibility to report changes in your medical status and provide feedback about your needs and expectations.You have the responsibility to participate in your health care decisions and ask questions if you are uncertain about your dental treatment or plan.
You have the responsibility to inquire about your treatment options and acknowledge the benefits and limitations of any treatment that you choose.You have the responsibility for consequences resulting from declining treatment or from not following the agreed upon treatment plan.You have the responsibility to keep your scheduled appointments.You have the responsibility to be available for treatment upon reasonable notice.You have the responsibility to adhere to regular home oral health care recommendations.You have the responsibility to adhere in good faith to the office’s policies,You have the responsibility to assure that your financial obligations for health care received are fulfilled.

Electronic Communication (E-mail and Text Messaging) 

Emailing and text messaging have become a very common and convenient way to communicate with virtually anyone. This allows you to conveniently communicate with our office via two way text messaging and/or electronic mail (e-mail). It is important to be aware, however, that there are uncertainties related to the privacy and confidentiality of electronic communications. The “take home message” of this document is that We cannot ensure the confidentiality of any form of communication through electronic media other than encrypted secure email (password required). If you prefer to communicate via regular email and/or text messaging for issues regarding but not limited to scheduling your appointments, account statements, etc., we will be glad to do so. Please be advised, however, of the following conditions:

  • Emailing and texting is not appropriate for urgent or emergency situations. For medical emergencies call 911. We cannot guarantee that any particular email and/or text will be read and responded to within any particular period of time.
  • E-mails and text messages are only read by our staff during working hours. 
  • E-mail and texts should be concise. The patient should call and/or schedule an appointment to discuss complex and/or sensitive situations.
  • H&L Dentistry will not forward a patient’s identifiable emails and/or texts without the client’s written consent, except as authorized by law.
  • Providers and staff are not liable for any breaches of confidentiality caused by the client or any third party.  
  • SMS messages are not encrypted. This makes them easier for you to receive but this means that there is a potential for other people to access that information. For making payments via text, e-mail  or online, an encrypted secure link will be provided.


appointment Policy

We thank you for trusting our practice with your dental health needs. So that our practice can continue to run smoothly and we maintain a healthy patient/doctor relationship, the following policies have been implemented and we ask for your compliance:

Please be on time for your appointments. We will in turn continue to do everything in our power to respect your time and to keep you from waiting. If a patient is late for their appointment, it makes it impossible for us to stay on schedule, inconveniencing those with appointment times to follow. If you must change a scheduled appointment time, please give us at least 48 hours notice. This is a necessity for us and a courtesy to other patients who are waiting to have their dental treatment needs met. With enough notice we may be able to provide other patients with the opportunity to make an appointment to receive care. When appointments are not kept we lose the opportunity to render a much-needed service to another patient. We hereby notify you that we reserve the right to charge a fee of $50.00 for missed appointments or appointments canceled with less than 48 business hours notice. Missed or canceled appointments will be billed to your dental insurance with ADA CDT codes D9986 or D9987 whichever applies. 


Restorative Procedures/Use of Anesthesia if needed

Restorative Procedures and Use of Anesthesia Treatment

Restorative procedures include tooth colored restorations or fillings made of silver (amalgam) fillings, crowns and bridges. Fillings are placed to restore damaged teeth and/or to enhance their appearance. The tooth is first modified or prepared by the use of a drill and an accompanying water spray. The tooth is then restored with the selected filling material.
Crowns and Bridges are placed to strengthen teeth weakened by tooth decay or root canal therapy and to replace missing teeth. This treatment involves modifying the teeth with the drill and accompanying water spray. A temporary crown or bridge is made to fit over the tooth/teeth while the final crown or bridge is being made. An impression of the modified tooth/teeth is necessary for fabrication of the new crown/bridge. Cement is used to fix the crown/bridge on to the modified tooth/teeth.
Local anesthesia is delivered from a sterile syringe and needle assembly. Types of
anesthesia commonly used include lidocaine with epinephrine, articaine with epinephrine and mepivacaine without epinephrine among others.

The proposed treatment is intended to restore or improve the appearance and strength of your teeth as well as the way your teeth fit together.

Depending upon your needs, alternative treatments include extracting damaged teeth or correcting your bite with orthodontic treatment instead of placing crowns and bridges. Bleaching can be an alternative to cosmetic restorative treatment.

Common Risks
Reactions to anesthesia: an allergic reaction to local anesthesia is rare. If you do have an allergic reaction, first aid will be rendered immediately at our office.
Continued medical attention at a hospital may be required. A normal reaction to the anesthetic if injected into a blood vessel can cause transient heart palpitations along with fainting. Localized swelling and bruising can also occur. Altered nerve Junction is a rare but significant risk in the administration of a local anesthetic. If the needle penetrates the nerve, there can be a partial or complete loss of nerve function. Both sensation and motor control can be altered after the local anesthetic wears off. The nerve damage usually resolves over a period of weeks to months. Permanent damage is a rare but possible occurrence. Irritation to nerve tissue: preparation of a tooth for a filling or a crown may irritate the
nerve tissue (pulp) inside the tooth, leaving your tooth feeling sensitive to temperature and/or pressure. This sensitivity is most commonly a transient side effect of treatment resolving in the weeks and sometimes months after treatment. Taking ibuprofen (Advil) or acetaminophen (Tylenol) can help to resolve this situation. In some cases, despite our best care, teeth which have been filled or crowned may require root canal therapy
following treatment.

Stiff or sore jaw joint: holding your mouth open during treatment may temporarily leave your jaw feeling stiff and sore making it difficult to open your mouth wide for several days after treatment Taking ibuprofen or acetaminophen and applying moist heat to the affected area for a few days improves most symptoms.
Consequences of not performing treatment
If you do not have the recommended restorative treatment, existing problems caused by the shape or position of your teeth could result in further discomfort and possible damage to your jaw joints. For teeth that have received root canal treatment, failure to place a crown could lead to pain, infection and possibly the premature loss of the tooth. Decayed, cracked or broken teeth or teeth with inadequate restorations could continue to deteriorate, causing pain, further decay, infection, deterioration of the bone surrounding the tooth and eventually tooth loss.

Every reasonable effort will be made to ensure that your condition is treated properly. Perfect results cannot be guaranteed and risks to treatment can lead to further dental and/or medical treatment. 

If you have any questions about payments or insurance, please call us at H&L Dentistry Phone Number (919) 213-0505 – we are here to help!

 Revised 12-2023