Just as we are committed to providing you with the best endodontic experience, we are also concerned with keeping our fees for service reasonable. One way we can accomplish this is by eliminating costly billing procedures and requesting payment at the time of your visit with us.

• For your convenience, we accept payment by cash, check, and credit cards that include Visa, MasterCard, American Express and Discover. We also offer affordable payment options through Care Credit.
• We are happy to submit your insurance claim and any necessary images. Please provide us with your personal and employer information and your insurance card. Your insurance carrier will directly reimburse you. If you do not hear from your insurance carrier within 4-6 weeks of your visit, please call our office and we will check on the status of your claim.
• A charge of $50.00 will be added to an account for any check returned by the bank due to insufficient funds.

We do not want or expect you to postpone necessary treatment. We will do our best to help you plan for the costs of treatment. Claims are filed electronically.

Our Legal Duty

We are required by applicable federal and state law 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 takes effect 4/14/03 and will remain in effect until we replace it.

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. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

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 using the information listed at the end of this Notice.

Uses and Disclosures of Health Information

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

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

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 performance conducting training programs, accreditation, certification, licensing or credentialing activities.

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 a 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.

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.

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 filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law.

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.

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 correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

Patient Rights

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. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies we will charge you $1.00 per page and any postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)

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, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12 month period, we may charge you a reasonable, cost based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use 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).

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation 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. (Your 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: I you receive this Notice on our Web site or by electronic mail (e-mail); you are entitled to receive this Notice in written form.

Questions and Complaints

If you want more information about our privacy practices or have questions or concerns, please refer all questions to the doctor.

If you are concerned that we may have violated your privacy rights or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Instructions following your root canal

We hope that your experience here has been as pleasant as possible, knowing the tooth or teeth treated were saved for future use and enjoyment. This sheet will go over some information about what to expect for the next few weeks and instructions for the healing phase.

DO NOT eat on the treated tooth until after you see your general dentist, especially anything hard (peanuts, pretzels, ice, etc.) until the permanent crown/filling has been placed on the tooth. The tooth may be tender to bite or could fracture.

Normal: Some discomfort, depending on the circumstances prior to the treatment, the tooth and surrounding tissues may remain sore for a few weeks following treatment. The most common are:

• A dull or sharp ache specific to the treated tooth or jaw area.
• Soreness of the gum tissue due to anesthetic injections or the dental dam.
• Headache or soreness of your jaw muscles from having your mouth open a prolonged time.
• Numbness that may last for several hours after the procedure or longer.  Be careful not to bite your lip, tongue, or cheek.
• Your tooth may continue to feel slightly different from your other teeth for some time after the treatment is completed. You can feel sensations from the nerves in the gum surrounding your tooth.
• You may floss and brush your tooth as normal.
• What do I do about the pain? These conditions should be relieved with over-the-counter analgesics like Advil, Motrin, or Tylenol, warm salt water rinses, a warm compress, or an ice pack:
  • If an antibiotic was prescribed, you may wish to consider taking a probiotic to alleviate GI side effects.
  • A temporary restoration was placed in the tooth today.  Since it is temporary, it can wear away or even break.  It is imperative and your responsibility that once the root canal is completed, you need to follow up with your general dentist within one month to have a permanent filling, or crown (cap) placed.  Delaying the permanent restoration could cause the root canal to fail from bacterial invasion from your own saliva and may need to be done again.  Please call your general dentist once you have completed treatment with our office.  Any problems with this time frame please let us know.
  • Advil/Motrin/Ibuprofen 400-600 mg. every 4-6 hours as needed for pain (if you can tolerate). (Not to exceed 2400mg/day)
  • Tylenol 500-1000 mg. every 6 hours as needed for pain. (Not to exceed 3000mg/day)
  • Warm salt-water rinses – 1 teaspoon salt in 8-12 oz. of water.
  • Place bag of ice (or frozen bag of vegetables), or a warm compress on treated area 20 minutes on and 20 minutes off.
  • Prescribed medications should be taken as directed by Dr. Kusienski (if needed).

Abnormal (Of concern): post-treatment sensitivity would include: (Please call our office if any of these conditions exist.)

• Swelling or increased swelling in the treated area.
• Discomfort that does not respond to over-the-counter medications and/or those prescribed by Dr. Kusienski.
• A feeling that the tooth treated may be higher than the others when you bite.

You will receive a notification in 6 months for you to schedule a check up for your treated root canal tooth. We will take an image to ensure that everything is healing properly. If there are any additional questions or concerns, please feel free to ask.  Thank you for trusting us with your endodontic care. We look forward to serving you or anyone you refer to us in the future with the same courtesy and respect.

To download and print these instructions click here. 

Consent for Endodontic Therapy

Informed consent:  It is our belief that you should be informed about the following treatment and give consent before starting that treatment.  Discussion of possible complications is not meant to alarm you but rather, it is a necessity in the Commonwealth of Pennsylvania to inform the patient of possible risks associated with this procedure.

Benefits and alternatives:  Endodontic therapy (Root canal) is a commonly performed and generally safe dental procedure that is intended to allow you to retain your tooth for a longer period of time.  This involves the removal of tissue in the center of the tooth (Root canal) and the sealing of that space.  Treatment will be performed in a manner to minimize/avoid risks.  Although root canal therapy has a high degree of success, the results cannot be guaranteed.  Other alternatives include no treatment, waiting for definitive symptoms to develop or having the tooth extracted.  Risks involved with these choices may include pain, swelling, infection, loss of the tooth, hospitalization and even death.

Risks:  The risks of treatment include, but are not limited to: loss of taste, speech, sight, or feeling (numbness – temporary or permanent), muscle cramps and spasms; referred to pain in the ear, neck and head, nausea, vomiting, allergic reactions, bruises, delayed healing, sinus complications, further surgery or even death may result with any, but is not limited to the risks below:

1. Bleeding, pain, soreness and infection: During and after treatment, you may experience bleeding, pain, swelling, infection or discomfort for several days which may need to be treated with medication, further treatment or hospitalization. If you have taken or are taking antiresorptive drugs (denosumab), antiangiogenic drugs and bisphosphonate class of drugs (“bone building” drugs), please notify us so that we may review the specific risks associated with these medications.
2. Reaction to anesthesia and/or sedation:  To keep you comfortable during treatment you will receive a local anesthetic with the possibility of other sedative medications (i.e. nitrous oxide) if necessary.  In rare instances, you may have an allergic reaction which may require emergency medical attention.  Other possible complications include numbness (temporary or permanent), muscle cramps and spasms, nausea, vomiting, bruising, further surgery or even death.
3. Stiff or sore jaw:  Holding your mouth open during any treatment may temporarily leave your jaw feeling stiff and sore for several days afterwards.  Treatment may also leave the corners of your mouth red or cracked for several days.  Additional treatment may be necessary to correct the jaw stiffness or soreness.
4. Broken instrument:  Occasionally, a root canal instrument will break off in a tooth canal that is twisted, curved, or calcified (blocked with calcium deposits).  Depending on its location, the fragments may be retrieved or sealed in the permanent root canal filling material.  These instruments are made of sterile nontoxic stainless steel or nickel-titanium.  It may also be necessary to perform further treatment to retrieve the instrument.
5. Need for further treatment:  In some cases, root canal treatment may not relieve all symptoms and you may need further treatment.  Following completion of the root canal, it is necessary to follow-up with your general dentist to have a permanent restoration placed.  If you do not have a permanent restoration placed in a timely fashion, you place yourself at risk for failure of the root canal treatment.

I acknowledge and agree that I have read the above carefully.  I understand that Dr. Kusienski may utilize my digital images for educational purposes and that my identity would remain anonymous.  I consent to the endodontic therapy procedure(s) deemed necessary or advisable by Dr. Kusienski and all questions have been addressed to my satisfaction.

Patient/Guardian Signature:  _________________________________
Date:  ________________________________

Witness Signature:   ________________________________________
Date:  _______________________________

Doctor Signature:  _____________________________________
Date:  _____________________________

I understand that it is imperative and my responsibility that once the root canal is completed, I will need to follow up with my general dentist within one month to have a permanent filling, or crown (cap) placed.

Patient/Guardian Signature:  ________________________________
Date:  ________________________________