Forms, Payment Options
& Privacy
At SmileWorks, we believe great dental care should be accessible. We work with most major insurance plans and offer flexible payment options — and we take your privacy seriously.
Forms
Save time in the waiting room by downloading new patient forms online. You may print them or email them to [email protected].
Payment Options
SmileWorks is an independent practice offering in-network pricing with most major dental insurance plans. We are committed to making your care as affordable as possible.
Our patients are always welcome to discuss treatment options and fees before any treatment begins. In an effort to keep fees down while maintaining the highest level of independent, professional care, we have established the ability for our patients to make financial arrangements over time for extensive treatments, we accept credit cards, and we also work with CareCredit patient financing.
A Special Note About Dental Policies
Dental care at SmileWorks is provided to you, our patient, and not to an insurance company. A dental policy is an agreement among the insurance company and the patient, and the patient is responsible to the doctor. Still, as a service to our patients, we offer in-network claims filing with most insurance providers and are ready to help answer any questions you may have.
Have questions about your insurance or billing? Call us at (972) 961-0800 — we're happy to help.
Notice of Privacy Practices
Effective Date: January 1, 2020 · Clay H. Ainley DDS PC
Our Commitment to Your Privacy
Clay H. Ainley DDS PC ("SmileWorks Dentistry") is committed to protecting the privacy of your health information. This Notice describes how we may use and disclose your protected health information (PHI) and your rights regarding that information, in accordance with the Health Insurance Portability and Accountability Act (HIPAA).
How We Use Your Information
We may use and disclose your health information for the following purposes:
- Treatment — to provide, coordinate, or manage your dental care.
- Payment — to bill and collect payment for services rendered.
- Healthcare Operations — for quality assessment, training, and administrative purposes.
- As Required by Law — when required by federal, state, or local law.
- Public Health Activities — to report disease, injury, or vital statistics as required.
Your Rights
You have the right to:
- Request a copy of your health information.
- Request corrections to your health information.
- Request restrictions on how we use or disclose your information.
- Request confidential communications.
- Receive an accounting of disclosures of your health information.
- Receive a paper copy of this Notice upon request.
Our Responsibilities
We are required by law to maintain the privacy of your health information, to provide you with this Notice, and to follow the terms of the Notice currently in effect. We reserve the right to change our privacy practices and the terms of this Notice. Changes will apply to health information we already hold as well as new information. The current Notice will always be available at our office and on our website.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with our office or with the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint.