STATEMENT OF PRIVACY PRACTICES
FOREST FAMILY DENTISTRY
Forest Family Dentistry collects and maintains a record of the health care services we provide you. In keeping with the Health Insurance Portability and Accountability Act (HIPAA), and the State of TX, we are dedicated to protect your rights of privacy and the confidential information entrusted to us.
The commitment of each employee to ensure that your health information is never compromised is a principal concept of our practice. We will not disclose your protected health information unless you direct or authorize us to do so or unless it is otherwise allowed or compelled by law. We may, from time to time, amend our privacy policies and practices but will always inform you of any changes that might affect your rights.
You may see your record or get more information about it at the “Your Individual Rights about Patient Health Information” section of the Notice. You may request to review and copy your personal record and you may also request that we make corrections to the record.
OVERVIEW
Our Statement of Privacy Practices is currently in effect and provides information about the use and disclosure of protected health information by Forest Family Dentistry and our employees. It is applicable in all instances wherein individually identifiable health information is collected from you and services are provided for you. Our Statement:
In Synopsis form, you have a right to:
1equest restricted use of your health information. (Please understand that we may not agree to your request),
2. Request that we not disclose your health plan of services for which you self-pay in full,
3. Request that we communicate with you by alternate methods,
4. Review and receive copies of your personal health record,
5. Request for amendments and/or changes be made to your record,
6. Request an accounting of disclosures of your health information,
7. File complaints related to failure to protect the privacy of your health information,
8. Direct us not to share information with your family members,
9. Request that you not be listed in/on our facility directory.
PROTECTED HEALTHCARE INFORMATION
It is important that you not only that we limit requests for your personal information to that needed to provide quality health care, important payment activities, and conduct normal health practice operations, but understand what “Protected Healthcare Information” is. This may include your name, address, telephone number(s), Social Security Number, employment data, dental history, health records, and/or any personal information that is unique to you.
While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law.
PROTECTING YOUR PERSONAL HEALTHCARE INFORMATION
We use and disclose the information we collect from you only as allowed by the HIPAA and the state of TX. This includes when it is used and disclosed to perform treatment, obtain payment, and conduct operational activities. Your personal health information will never be otherwise given to anyone - even family members - without your written consent. You, of course, may give written authorization for us to disclose your information to anyone you choose, for any purpose.
Our Statement of Privacy Practices applies to all personal health information collected or created by Forest Family Dentistry or received from outside healthcare providers. This information may identify you, relate to your past, present or future physical or mental condition, the care provided, or any reference to payment for your health care. For example, protected health information includes symptoms, test results, diagnoses, health information from other providers, as well as billing and payment information relating to these services. This information is protected because it is often part of your health or dental record, which we can use as:
10. A method by which we can ensure your record’s accuracy,
11. A system to assist you to more clearly understand the circumstances and conditions in and by which others may have access to your personal information.
12. A tool for us to make more informed decisions when authorizing disclosures to others.
USE AND DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION - WITHOUT YOUR AUTHORIZATION
As stated above we may, under allowed circumstances, use and disclose protected health information (PHI) without your specific authorization. Examples of such instances are included below:
Treatment: We may use and disclose your PHI to provide treatment. For example, we can:
Payment: We may use your health information for payment purposes. Such instances may include:
Health Care Operations: We may use and disclose your health information to support the daily activities related to health care. Examples include:
Train Staff and Students: We may use and disclose your information to teach and train staff how to review patient health information.
Contact You for Information: Your PHI may also be used to contact you. In example, we may call you or send you a letter to remind you about your appointment, provide test results, inform you about treatment options, or advise you about other health-related benefits and services.
Business Associates: Your PHI may be used by Forest Family Dentistry and disclosed as needed to individuals, organizations, or companies to comply with our legal obligations described in this Notice. An example is disclosure of your PHI to consultants, attorneys, or third parties to assist in our business activities. All such entities must sign a Business Associate Agreement to protect the confidentiality of your private information.
ADDITIONAL USES AND DISCLOSURES
We also use and disclose your information to enhance health care services, protect patient safety, safeguard public health, ensure that our facilities and staff comply with government and accreditation standards, and when otherwise compelled or allowed by law. For example, we provide or disclose information:
10. For court order or lawful subpoena.
11. To coroners, medical examiners, and funeral directions.
12. To government officials when required for specifically identified functions such as national security.
13. When otherwise required by law, such as to the Secretary of the United States Department of Health and Human Services for purposes of determining compliance with our obligations to protect the privacy of your health information.
14. If you are a member of the armed forces, we may release dental information about you as required by military command authorities. We may also release dental information about foreign military personnel to the appropriate foreign military authority.
YOUR RIGHTS TO OBJECT
Disclosure to Family, Friends, or Others. You may object to our disclosing your general health condition (“good”, “fair”, “critical”, etc.) to an individual, or individuals, you have identified who have an active interest in your care, payment for your health care, or who may need to notify others about your general condition, location, or death. If you do not so indicate, we will use our best professional judgment to provide relevant protected health information to your family member, friend, or another identified person.
USE AND DISCLOSURES REQUIRING YOUR AUTHORIZATION
Our offices and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality of your records is always protected. Our privacy policy and practices apply to all former, current, and future patients, so you can be confident that your protected health information will never be improperly disclosed or released.
Other than the uses and disclosures described above, we will not use or disclose your protected health information without your written authorization. You may revoke your written authorization, at any time unless prohibited by law, or disclosure is required for us to obtain payment for services already provided, or we have otherwise relied on the authorization.
ADDITIONAL PROTECTION OF YOUR PATIENT HEALTH INFORMATION
Special state and federal laws apply to certain classes of patient health information. For example, additional protections may apply to information about sexually transmitted diseases, drug and alcohol abuse treatment records, mental health records, and HIV/AIDS information. When required by law, we will obtain your authorization before releasing this type of information.
YOUR INDIVIDUAL RIGHTS ABOUT PATIENT HEALTH INFORMATION
You may contact Forest Family Dentistry to exercise your rights related to the use and disclosure of your protected health information. You may contact us at:
Forest Family Dentistry
2700 W Anderson Lane, #418
Austin, TX 78757
Attn: Dr. Bethell
512-334-9894
Your specific rights are listed below and include:
U.S. Department of Health and Human Services,
Office of Civil Rights:
1301 Young Street, Suite 1169
Dallas, TX 75202
Voice: 800-368-1019 | Fax: 214-767-0432
TDD: 800-537-7697
BREACH NOTIFICATION
If it is found that your patient information is used or disclosed in a manner that is not consistent with the practices described in this notice, Forest Family Dentistry will fully investigate the matter to assess if there was a breach in the protection of your PHI. The assessment will be conducted to determine whether the information that was used or disclosed has significant risk of physical, financial, or reputational harm to you. If so, Forest Family Dentistry will notify you and Health and Human Services in writing.
PRIVACY NOTICE CHANGES
We are required by law to protect the privacy of your information, to provide this Statement of Privacy Practices and to follow the privacy practices that are described herein. We reserve the right to change the privacy practices described and the right to make the revised or changed Statement effective for protected health information we already have as well as any information we may receive in the future.
We have posted a copy of our current Statement for your review and reference. Additionally, each time you visit our office for treatment or health care services, you may request a copy of our current Statement of Privacy Practices. An electronic version of the notice is posted on our website.