NOTICE OF PRIVACY PRACTICES
I. OUR LEGAL DUTYForwardDental (referred to herein as “We” or “Our”) is required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice of Privacy Practices (“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. The original Notice took effect April 14, 2003 and has been amended effective as of August 1, 2015. The amended Notice shall and will remain in effect until we further amend or replace it.
II. TO WHAT INFORMATION DOES THIS NOTICE APPLY?Protected Health Information (PHI) is information that you provide us or that we create or receive about your dental care. PHI includes a patient’s name, age, race, sex, and other personal health information that may identify the patient. The information relates to the patient’s physical or mental health in the past, present, or future, and to the care, treatment, services and payment for care needed by a patient because of his or her health.
III. WAYS WE CAN USE AND SHARE YOUR PHI WITHOUT YOUR WRITTEN PERMISSION (OR AUTHORIZATION)In many situations, we can use and share your PHI for activities that are common in dental practices. In certain other situations, which we will describe below, we must have your written permission (authorization) to use and/or share your PHI. We do not need any type of permission from you for the following uses and disclosures:
A. We must use and disclose your health information to provide that information:
a. To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this Notice; and
b. To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected.
B. Uses and Disclosures for Treatment, Payment and Health Care Operations. We may use and share your PHI to provide "Treatment," obtain "Payment" for your Treatment, and perform our "Health Care Operations.” This is what these terms mean:
a. Treatment. We use and share your PHI to provide care and other services to you--for example, to diagnose and treat your dental condition. In addition, we may contact you to provide appointment reminders or information about treatment options. We may tell you about other health-related benefits and services that might interest you. We may also share PHI with other dental specialists, dentists, hygienists, assistants, and others involved in your care.
b. Payment. We may use and share your PHI to receive payment for services that we provide to you. For example, we may share your PHI to request and receive payment from your health insurer or other company or program that arranges or pays the cost of some or all of your dental care ("Your Payor") and to confirm that Your Payor will pay for dental care. As another example, we may share your PHI with the person who you told us is primarily responsible for paying for your Treatment, such as your spouse or parent.
c. Health Care Operations. We may use and share your PHI for our health care operations, which include management, care coordination, planning, and activities that improve the quality and lower the cost of the care that we deliver. For example, we may use PHI to review the quality and skill of our dentists, hygienists, and other dental care providers. We may use your PHI to conduct quality assessment and improvement activities, including outcomes evaluation and the development of clinical guidelines. We may also use your PHI to participate in population-based activities relating to improving health or reducing dental care costs. Also, we might use your PHI to provide you information on health related programs or products such as alternative dental treatments and programs or about health-related products and services, subject to limits imposed by law.
C. Disclosures to Your Other Health Care Providers. We may also share PHI with other dental or health care providers when they need it to provide Treatment to you, to obtain Payment for the care they give to you, to perform certain Health Care Operations, such as reviewing the quality and skill of dental care professionals, or to review their actions in following the law.
D. Disclosure to Relatives, Close Friends and Your Other Caregivers. We may share your PHI with your family member/relative, a close personal friend, or another person who you identify if we (1) first provide you with the chance to object to the disclosure and you do not object; (2) infer that you do not object to the disclosure; or (3) obtain your agreement to share your PHI with these individuals. If you are not present at the time we share your PHI, or you are not able to agree or disagree to our sharing your PHI because you are not capable or there is an emergency circumstance, we may use our professional judgment to decide that sharing the PHI is in your best interest. We may also use or share your PHI to notify (or assist in notifying) these individuals about your location and general condition.
E. To Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. Our business associates are required, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
F. For Data Breach Notification Purposes. We may use your contact information to provide legally-required notices of unauthorized acquisition, access, or disclosure of your health information.
G. Public Health Activities. We are required or are permitted by law to report PHI to certain government agencies and others. For example, we may share your PHI for the following:
a. to report health information to public health authorities for the purpose of preventing or controlling disease, injury, or disability;
b. to report known or suspected abuse or neglect to the appropriate public child protective services agency, as we are required to do by law;
c. to report information about products and services to the U.S. Food and Drug Administration;
d. to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of developing or spreading a disease or condition;
e. to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance; and
f. to prevent or lessen a serious and imminent threat to a person for the public's health or safety or to certain government agencies with special functions such as the State Department.
H. Health Oversight Activities. We may share your PHI with a health oversight agency that oversees the health care system and ensures the rules of government health programs, such as Medicaid, are being followed.
I. Judicial and Administrative Proceedings. We may share your PHI in the course of a judicial or administrative proceeding in response to a court order or other lawful process.
J. Law Enforcement Purposes. We may share your PHI with the police or other law enforcement officials as required or permitted by law or in compliance with a court order or warrant.
K. Decedents. We may share PHI with a coroner or medical examiner as authorized by law.
L. Workers' Compensation. We may share your PHI as permitted by or required by state law relating to workers' compensation or other similar programs.
M. As Required by Law. We may use and share your PHI when required to do so by any other law not already referred to above.
IV. USES AND DISCLOSURES REQUIRING YOUR WRITTEN PERMISSION (OR AUTHORIZATION)
A. For any purpose other than the ones described above, we may only use or share your PHI when you grant us your written permission (authorization). Our use or disclosure will be consistent with such written permission (authorization). You may revoke any written permission (authorization).
B. Marketing. We must also obtain your written permission (authorization) prior to using your PHI for marketing materials, except if the communication is in the form of a face-to-face communication made by us to an individual, or a promotional gift of nominal value provided by us. If the marketing involves financial remuneration to us from a third party, the authorization will state that such remuneration is involved.
C. Sale of PHI. We must obtain your written permission (authorization) prior to selling your PHI, or in the instance that disclosure of your PHI will result in remuneration to us.
D. Uses and Disclosures of Your Highly Confidential Information. Federal and state law requires special privacy protections for certain highly confidential information about you ("Highly Confidential Information"), including any portion of your PHI that is: (1) about mental health and developmental disabilities services; (2) about alcohol and drug abuse prevention, Treatment and referral; (3) about HIV/AIDS testing, diagnosis or Treatment; (4) about sexually transmitted disease(s); (5) about child abuse and neglect; or (6) about sexual assault. For any of the foregoing, we must obtain your written permission (authorization) for any use or disclosure, except to carry out certain treatment, payment, or health care operations. Before we share your Highly Confidential Information for a purpose other than those permitted by law, we must obtain your written permission.
V. PATIENT RIGHTS
A. You have the right to be informed of our privacy practices.
a. Our practices related to protecting the privacy of your health information are described this Notice. The Notice describes how we use your information to provide treatment to you, to obtain payment for that treatment and for our internal business operations. You will be given the opportunity to obtain a paper copy of the Notice anytime you visit. When you first become our patient, we will ask you to sign an acknowledgement indicating that you have been given the opportunity to review and/or obtain a paper copy of our Notice. A current version of our Notice can also be viewed on our website at www.forwarddental.com.
B. You have the right to request access to your health information.
a. You have the right to see and obtain a copy of health information that may be used to make decisions about you, such as dentist’s notes, lab tests, prescriptions, and treatment plans. You also may in some cases receive a summary of this health information. You must make a written request to inspect and copy your health information. Mail or email your request to the address listed below. We may charge a reasonable fee for any copies.
b. In certain limited circumstances, we may deny your request to inspect and copy your health information. For example, you may not read or be given a copy of information collected for use in a civil, criminal, or administrative action, or court case; and certain PHI that is protected by law. In some situations, you may have the right to have this decision reviewed. Please contact the Privacy Officer listed below if you have questions about access to your health information.
C. You have the right to request that we disclose your health information to others.
a. If you would like some, or all of your health information sent to someone else, for example to another dentist or to your employer, you will need to complete our authorization form indicating that you agree to our disclosing (providing) the information to the others you select. The authorization form is available upon request in our office. Mail or email your request to the address listed below.
b. Once you authorize us to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization at any time, in writing, by mailing or emailing your revocation to the address below, except where we have already acted based on your authorization.
c. If we maintain an electronic health record containing your health information, when and if we are required by law, you will have the right to request that we send a copy of your health information in an electronic format to you or to a third party that you identify. We may charge a reasonable fee for sending the electronic copy of your health information.
D. You have the right to request to amend your health information.
a. You have the right to ask to amend health information we maintain about you if you believe the health information is wrong or incomplete. Your request must be in writing and provide the reasons for the requested amendment. The amendment form is available upon request in our office. Mail or email your request to the address listed below. We will review the information as requested and either make the correction or let you know why we think our information is correct. If we deny your request, you may give us a written statement disagreeing with our decision that we will keep with your health information.
E. You have the right to request to receive communications related to your health in another way or at other locations.
a. We normally send your healthcare information to the address and phone numbers you have provided. However, if you would like to have the information sent elsewhere to protect your privacy, you may do so. We will not ask you to explain why you are making the request. We will agree to reasonable requests. To carry out the request, we will ask you for another address or another way to contact you, for example, mailing to a post office box. The private communication form is available upon request in our office. Mail or email your request to the address listed below.
F. You have the right to request restrictions on the use and disclosure of your health information.
a. You have the right to ask to restrict uses or disclosures of your health information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your dental care or payment for your dental care. While we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction.
b. We may also have policies on minors that permit your minor child to request certain limits on your access to their health information.
c. If you pay out of pocket in full for specific services, you may request that PHI about that service not be disclosed to your dental plan. We will try to honor your request and will permit such requests consistent with our policies.
d. The restriction request form is available upon request in our office. Mail or email your request to the address listed below.
G. You have the right to request an accounting of people to whom we have disclosed your health information.
a. You have the right to receive an accounting of certain disclosures of your health information made by us during the six years prior to your request. This accounting will not include disclosures of information made: (i) prior to April 14, 2003; (ii) for treatment, payment, and health care operations purposes; (iii) to you or pursuant to your authorization; (iv) to law enforcement officials; and (v) other disclosures for which federal law does not require us to provide an accounting. The accounting request form is available upon request in our office. Mail or email your request to the address listed below.
H. You have the right to express concerns or to ask questions.
a. If you have any concerns about the privacy of your health information or if you have questions about our procedures, you may contact our Privacy Officer at:
Attn: Privacy Officer
PO Box 423
Germantown, WI 53022
I. You have the right to file a complaint.
a. If you believe your privacy rights have been violated, you may file a complaint with us at the address listed above. You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint at https://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html.
We will not take any action against you for filing a complaint.