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Privacy Policy

Statement of Privacy Practices

Our office is dedicated to protect the privacy rights of our patients and the confidential information entrusted to us. It is a requirement of this practice that every employee receive appropriate training and is dedicated to the principal concept that your health information shall never be compromised. We may, from time to time, amend our privacy policies and practices but will always inform you of any changes that might affect your obligations any your rights.

Protecting Your Personal Health Information

We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and Accountability Act and the state of Washington. This includes issues relating to your treatment, payment and our health care operations. your personal health information will never be other wise given or disclosed to anyone-even family members without your consent or written authorization. You of course, may give written authorization for us to disclose your information to anyone you choose, for any purpose.

Our offices and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality, integrity and access to 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 release.

Collecting Protected Health Information (PHI)

We will only request personal information needed to provide our standard of quality health care, implement payment activities, conduct normal health practice operations, and comply with the law. This may include your name, address, telephone number(s), Social Security Number, employment data, medical history, health records, etc. 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.

Disclosure Of Your Protected Health Information

As stated above, we may disclose information as required by law. We are obligated to provide information to law enforcement and governmental officials under certain circumstances. We will not use your information for marketing or fund-raising purposes without your written consent. We may use and/or disclose your health information to communicate reminders about your appointments including voicemail messages, answering machines and postcards unless you direct us otherwise. We will never use, disclose, sell, or otherwise allow access to your personal, protected information in exchange for or receipt of financial remuneration.

Any breach in the protection of your personal health information, including unauthorized acquisition, access, use, or disclosure, will be fully investigated, addressed, and mitigated as established by the HIPAA Privacy Breach Notification Rule. You have a right to and will be provided all information relating to any breach involving your personal PHI.

Your Rights As Our Patient

You have a right to request copies of your healthcare information; to request copies in a variety of formats; and to request a list of instances in which we, or our business associates, have disclosed your protected information for uses other than stated above. All such requests must be in writing. We may charge for your copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately. You can also notify the U.S. Department of Health and Human Services.

If you’d like a full and complete copy of our Statement of Privacy Practices, please ask the front desk.

THIS STATEMENT OF PRIVACY PRACTICES DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE DISCLOSED AND HOW YOU CAN GET ACCDESS TO THIS INFORMATION. PLEASE READY CAREFULLY.

Forest Family Dental collects and maintains a records of the health care services we provide you. In keeping with the Health Insurance Portability and Accountability Act (HIPAA), and the State of Washington, 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 records or get more information about it at “Your Individual Rights about Patient Health Information” section of the Notice. You may request to review and copy your personal records and you may also request that we make corrections to the records.

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 Dental 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:

  1. Defines your rights and our obligations when using your health information.

  2. Informs you about laws that provide special protections.

  3. Explains how your protected health information is used an how, under certain circumstances, it may be disclosed.

  4. Tells you how changes in this statement will be made available to you.

In synopsis form you have a right to:

  1. Request restricted use of your health information. (Please understand that we may not agree to your request.)

  2. Request that we not disclose to 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 of 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 know not only that we limit requests for your personal information to that needed to provide quality health care, implement payment activities, and conduct normal health practice operations, but understand what “Protected Healthcare Information” is. This may include your name, address, telephone numbers(s), Social Security Number, employment data, medical 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 Washington. 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, ma 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 Dental or received from outside healthcare providers. This information may identify you, relate to your past, present or future physical or mental condition, the the care provided, or any reference to payment for your healthcare.

For example, protected health information includes symptom, 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 medical record, which we can use as:

  1. A method of communication among health professionals who contribute to your care.

  2. A legal record describing the care you received.

  3. A means by which you can verify that services billed were provided.

  4. A tool to educate health professionals.

  5. A source of data for medical research.

  6. A source of information for public health officials.

  7. A source of information for facility planning.

  8. A tool to assess and improve the care we provide.

  9. A method by which we can provide a better understanding of your record.

  10. A method by which we can ensure your records 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:

  1. Use your information to find out whether certain tests, therapies, and medicines should be ordered.

  2. Provide your information to staff members to better understand what your healthcare needs are, how to evaluate your response to treatment.

  3. Disclose your PHI to another one of your treatment providers in order to provide you with the best possible healthcare.

Payment: We may use your health information for payment purposes. Such instances may include:

  1. Preparation of claims for payment of services.

  2. Billing your insurance directly, including information that identifies you as well as your diagnosis, the procedures performed and supplies used so that we can be paid for the treatment provided.

  3. Collection activities (if necessary) to obtain payment for services.

Health Care Operations: We may use and disclose your health information to support the daily activities related to healthcare. Examples include:

  1. Use and disclosure to monitor and improve our health services.

  2. Use by authorized staff to review at portions of your records to perform administrative activities.

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 also be used by Forest Family Dental and disclosed to individuals, organizations, or companies to comply with our legal obligations as 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 healthcare 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:

  1. About FDA-regulated drugs and devices to the U.S. Food and Drug Administration.

  2. To government oversight agencies with data for health oversight activities such as auditing or licensure.

  3. To public health authorities with information on communicable diseases and vital records.

  4. To your employer, findings relating to the evaluation of work-related illnesses or injuries.

  5. To workers’ compensation agencies and self-insured employers for work related illness or injuries.

  6. To appropriate government agencies when we suspect abuse or neglect.

  7. To appropriate agencies or persons when we believe if necessary to avoid a serious threat to health or safety or to prevent serious harm.

  8. To organ procurement organizations to coordinate organ donation activities.

  9. To law enforcement when required or allowed by law, including the Office of Civil Rights to conduct OCR investigations.

  10. For court order or lawful subpoena.

  11. To coroners, medical examiners, and funeral directors

  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 Sates 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 medical information about you as required by military command authorities. We may also release medical 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 healthcare 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 Disclosure Require 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 law apply to certain classes of patient health information. For example, additional protections may apply to information about sexually transmitted disease, 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 Dental to exercise your rights related to the use and disclosure of your protected health information. You may Contact us at:

Forest Family Dental
1603 Grove Street
Marysville, WA 98270
Attn: Dr. Williams
(360) 651-1882

Your specific rights are listed included:

  1. The right to request restricted use: You may request in writing that we not use or disclose your information for treatment, payment, and/or operational activities except when authorized by you, when required by law, or in emergency circumstances. We are not legally required to agree to your request. If you request that we restrict the use of your private information, we will provide you with written notice of our decision about your request.

  2. The right to request non-disclosure to health plans: You have the right to request in writing that health care items or services for which you self-pay for in advance of your visit not be disclosed to your health plan.

  3. The right to receive confidential communications: You have the right to request that we communicate with you about medical matters in a particular way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to the address above. We will grant all reasonable requests. Your request must specify how or where you wish to be contacted.

  4. The right to inspect and receive copies: In most cases you have the right to inspect and receive a copy of certain health care information including certain medical and billing records. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

  5. The right to request an amendment to your record: If you believe that your information in your records is incorrect or that important information is missing, you have the right to request in writing that we make a correction or add information. In your request for the amendment, you must give a reason for the amendment. We are not required to agree to the amendment of your record but a copy of your request will be added to your record.

  6. The right to know about disclosures: You have the right to receive a list of instances in which we have disclosed your health information. Certain instances will not appear on the list such as disclosures for treatment, payment or health care operations or when you have authorized the use of disclosure. Your first accounting of disclosures in a calendar year is free of chare, any additional request within the same calendar year requires a processing fee.

  7. The right to make complaints: If you believe that we have violated your privacy, or you disagree with a decision we made about access to your records, you may file a complaint directly to Dr. Williams using the contact information above. Neither Dr. Williams nor any employee of Forest Family Dental will retaliate against anyone for filing a complaint.

You may also contact:

U.S. Department of Health and Human Services,
Office for Civial Rights:
2201 Sixth Aveenue-Mail Stop RX-11
Seattle, WA 98121-1831
(206)615-2290; (206)615-2296 (TTY)
(206)615-2297 (Fax)
Toll Free: 1 (800)362-1710; 1 (800)537-7697 (TTY)

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 Dental 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 Dental 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 received 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 healthcare services you may request a copy of our current Statement of Privacy Practices. An electronic version of the notice is posted at www.forestfamilydentalmarysville.com.