HIPAA Omnibus Notice of Privacy Practices

Effective Date: December 27, 2024
Forney Family Dentistry & Orthodontics
108 E US Hwy 80 Ste 190
Forney, TX, 75126
(972) 564-7575

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND / OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The terms of this Notice of Privacy Practices (“Notice”) apply to Forney Family Dentistry & Orthodontics, its affiliates, and its employees. Forney Family Dentistry & Orthodontics will share patients’ protected health information as necessary to carry out treatment, payment, and health care operations as permitted by law. 

We are required by law to maintain the privacy of our patient’s protected health information and to provide patients with Notice of our legal duties and privacy practices for protected health information. 

We are required to abide by the terms of this Notice for as long as it remains in effect. We reserve the right to change the terms of this Notice as necessary and to make a new notice of privacy practices effective for all protected health information maintained by Forney Family Dentistry & Orthodontics. 

We are required to notify you in the event of a breach of your unsecured protected health information. We are also required to inform you that there may be a provision of state law that relates to the privacy of your health information that may be more stringent than a standard or requirement under the Federal Health Insurance Portability and Accountability Act (“HIPAA”). 

You may obtain a copy of any revised Notice of Privacy Practices or information pertaining to a specific State law by mailing a request to the Privacy Officer at the address below. 

USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION

We may use and disclose your Protected Health Information in the following situations:

• Authorization and Consent: Unless outlined below, we will not use or disclose your protected health information for any purpose other than treatment, payment, or health care operations unless you have signed a form authorizing such use or disclosure. You have the right to revoke such authorization in writing, with such revocation being effective once we receive the request in writing; however, such revocation shall not be effective to the extent that we have taken any action in reliance on the authorization or if the authorization was obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy or the policy itself. 
• Treatment: We may use or disclose your Protected Health Information to provide medical treatment and/or services to manage and coordinate your medical care. For example, we may share your medical information with other physicians and health care providers, DME vendors, surgery centers, hospitals, rehabilitation therapists, home health providers, laboratories, nurse case managers, worker’s compensation adjusters, etc. to ensure that the medical provider has the necessary medical information to diagnose and provide treatment to you.
• Payment: Your Protected Health Information will be used to obtain payment for your health care services. For example, we will provide your health care plan with the information it requires prior to paying us for the services we have provided to you. This use and disclosure may also include certain activities that your health plan requires prior to approving a service, such as determining benefits eligibility and prior authorization.
• Health Care Operations: We may use and disclose your Protected Health Information to manage, operate, and support the business activities of our practice. These activities include, but are not limited to, quality assessment, employee review, licensing, fundraising, and conducting or arranging for other business activities. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your Protected Health Information, as necessary, to contact you to remind you of your appointment and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you. 
• Minors: Protected Health Information of minors will be disclosed to their parents or legal guardians unless prohibited by law.
• Required by Law: We will use or disclose your Protected Health Information when required by local, state, federal, and international law.  
• Abuse, Neglect, and Domestic Violence: Your Protected Health Information will be disclosed to the appropriate government agency if there is the belief that a patient has been or is currently the victim of abuse, neglect, or domestic violence and the patient agrees, or it is required by law to do so. In addition, your information may also be disclosed when necessary to prevent a serious threat to your health or safety or the health and safety of others to someone who may be able to help prevent the threat.
• Judicial and Administrative Proceedings:  As sometimes required by law, we may disclose your Protected Health Information for the purpose of litigation, including: disputes and lawsuits, in response to a court or administrative order, response to a subpoena; request for discovery; or other legal processes. However, the disclosure will only be made if efforts have been made to inform you of the request or obtain an order protecting the information requested. Your information may also be disclosed if required for our legal defense in the event of a lawsuit.
• Law Enforcement: We will disclose your Protected Health Information for law enforcement purposes when all applicable legal requirements have been met. This includes, but is not limited to, law enforcement due to identifying or locating a suspect, fugitive, material witness, or missing person, complying with a court order or warrant, and grand jury subpoena.
• Coroners and Medical Examiners: We disclose Protected Health Information to coroners and medical examiners to assist in fulfilling their work responsibilities and investigations.
• Public Health: Your Protected Health Information may be disclosed and may be required by law to be disclosed for public health risks. This includes reports to the Food and Drug Administration (FDA) for quality and safety of an FDA-regulated product or activity; to prevent or control disease; report births and deaths; report child abuse and/or neglect; reporting of reactions to medications or problems with health products; notification of recalls of products; reporting a person who may have been exposed to a disease or may be at risk of contracting and/or spreading a disease or condition.
• Health Oversight Activities: We may disclose your Protected Health Information to a health oversight agency for audits, investigations, inspections, licensures, and other activities authorized by law.
• Inmates: If you are or become an inmate of a correctional facility or under the custody of the law, we may disclose Protected Health Information to the correctional facility if the disclosure is necessary for your institutional health care, to protect your health and safety, or to protect the health and safety of others within the correctional facility.
• Military, National Security, and other Specialized Government Functions: If you are in the military or involved in national security or intelligence, we may disclose your Protected Health Information to authorized officials.
• Immunizations: We will provide proof of immunizations to a school that requires a patient’s immunization record before enrollment or admittance of a student in which you have informally agreed to the disclosure for yourself or on behalf of your legal dependent.
• Worker’s Compensation:  We will disclose only the Protected Health Information necessary for Worker’s Compensation in compliance with Worker’s Compensation laws. This information may be reported to your employer and/or your employer’s representative regarding an occupational injury or illness.
• Practice Ownership Change: If our medical practice is sold, acquired, or merged with another entity, your protected health information will become the property of the new owner. However, you will still have the right to request copies of your records and have copies of documents transferred to another physician.
• Breach Notification Purposes: If for any reason, there is an unsecured breach of your Protected Health Information, we will utilize the contact information you provided to notify you of the breach, as required by law. In addition, your Protected Health Information may be disclosed as a part of the breach notification and reporting process.
• Research: Your Protected Health Information may be disclosed to researchers to conduct research when an Institutional Review or Privacy Board has approved the research and complies with the law governing research.  
• Business Associates: We may disclose your Protected Health Information to our business associates who provide us with services necessary to operate and function as a medical practice. We will only provide the minimum information needed for the associate(s) to perform their tasks relating to our business operations. For example, we may use a separate company to process online form submission data, which requires access to a limited amount of your health information. Please know and understand that all of our business associates are obligated to comply with the same HIPAA privacy and security rules to which we are bound. Additionally, all of our business associates are under contract with us and committed to protecting the privacy and security of your Protected Health Information. 
  
  

USES AND DISCLOSURES IN WHICH YOU HAVE THE RIGHT TO OBJECT AND OPT-OUT  

• Communication with family and/or individuals involved in your care or payment of your care: Unless you object, disclosure of your Protected Health Information may be made to a family member, friend, or other individual involved in your care or payment of your care in which you have identified.  
• Disaster: In the event of a disaster, your Protected Health Information may be disclosed to disaster relief organizations to coordinate your care and/or to notify family members or friends of your location and condition. Whenever possible, we will provide you with an opportunity to agree or object.
• Fundraising: We may disclose your Protected Health Information to contact you regarding fundraising events and efforts. You have the right to object to or opt out of these communications. Please let our office know if you would not like to receive such communications.
   

USES AND DISCLOSURES THAT REQUIRE YOUR WRITTEN AUTHORIZATION

We will not disclose or use your Protected Health Information in the situations listed below without obtaining written authorization. In addition to the uses and disclosures listed below, other uses not covered in this Notice will be made only with your written authorization. If you provide us with consent, you may revoke it at any time by submitting a request in writing:

• Disclosure of Psychotherapy Notes: Unless we obtain your written authorization, we will not disclose your psychotherapy notes in most circumstances. Some circumstances in which we will disclose your psychotherapy notes include the following: for your continued treatment; training of medical students and staff; to defend ourselves during litigation; if the law requires; health oversight activities regarding your psychotherapist; to avert a serious or imminent threat to yourself or others, and the coroner or medical examiner upon your death.
• Genetic Information: We must obtain your specific written authorization before using or disclosing your genetic information for treatment, payment, or health care operations purposes. We may use or disclose your genetic information, or the genetic information of your child, without your written authorization, only where it would be permitted by law.
• Marketing: We must obtain your authorization for any use or disclosure of your protected health information for marketing, except if the communication is in the form of (1) face-to-face communication with you or (2) a promotional gift of nominal value.
• Sale of Protected Information: We must obtain your authorization before receiving direct or indirect remuneration in exchange for your health information; however, such authorization is not required where the purpose of the exchange is for: 
  • Public health activities; 
  • Research purposes provided that we receive only a reasonable, cost-based fee to cover the cost to prepare and transmit the information for research purposes; • Treatment and payment purposes; 
  • Health care operations involving the sale, transfer, merger, or consolidation of all or part of our business and for related due diligence; 
  • Payment we provide to a business associate for activities involving the exchange of protected health information that the business associate undertakes on our behalf (or the subcontractor undertakes on behalf of a business associate), and the only remuneration provided is for the performance of such activities; 
  • Providing you with a copy of your health information or an accounting of disclosures;
  • Disclosures required by law;
  • Disclosures of your health information for any other purpose permitted by and per the Privacy Rule of HIPAA, as long as the only remuneration we receive is a reasonable, cost-based fee to cover the cost to prepare and transmit your health information for such purpose or is a fee otherwise expressly permitted by other law; or 
  • Any other exceptions allowed by the Department of Health and Human Services. 
    
    

PROTECTED HEALTH INFORMATION AND YOUR RIGHTS

The following are statements of your rights, subject to certain limitations, with respect to your Protected Health Information:

• You have the right to inspect and copy your Protected Health Information (reasonable fees may apply): Pursuant to your written request; you have the right to inspect and copy your Protected Health Information in paper or electronic format. Under federal law, you may not inspect or copy the following types of records: psychotherapy notes, information compiled as it relates to civil, criminal, or administrative action or proceeding; information restricted by law; information related to medical research in which you have agreed to participate; information obtained under a promise of confidentiality; and information whose disclosure may result in harm or injury to yourself or others. We have up to 30 days to provide the Protected Health Information and may charge a fee for the associated costs.  
• You have a right to a summary or explanation of your Protected Health Information: You have the right to request only a summary of your Protected Health Information if you do not desire to obtain a copy of your entire record. You also have the option to request an explanation of the information when you request your entire record.
• You have the right to obtain an electronic copy of medical records. You have the right to request an electronic copy of your medical record for yourself or to be sent to another individual or organization when your Protected Health Information is maintained in an electronic format. We will make every attempt to provide the records in the format you request; however, if the information is not readily accessible or producible in the format you request, we will provide the record in a standard electronic format or a legible hard copy form. Record requests may be subject to a reasonable, cost-based fee for the work required in transmitting the electronic medical records.
• You have the right to receive a notice of breach: In the event of a breach of your unsecured Protected Health Information, you have the right to be notified of such breach.
• You have the right to request Amendments: At any time, if you believe the Protected Health Information we have on file for you is inaccurate or incomplete, you may request that we amend the information. Your request for an amendment must be submitted in writing and detail what information is inaccurate and why. Please note that a request for an amendment does not necessarily indicate the information will be amended.  
• You have a right to receive an accounting of certain disclosures: You have the right to receive an accounting of disclosures of your Protected Health Information. An “accounting” is a list of the disclosures that we have made of your information. The request can be made for paper and/or electronic disclosures and will not include disclosures made for: treatment, payment, health care operations; notification and communication with family and/or friends; and those required by law.  
• You have the right to request restrictions of your Protected Health Information: You have a right to restrict and/or limit the information we disclose to others, such as family members, friends, and individuals involved in your care or payment for your care. You also have the right to limit or restrict the information we use or disclose for treatment, payment, and/or health care operations. Your request must be submitted in writing and include the specific restriction requested, whom you want the restriction to apply, and why you would like to impose the restriction. Please note that our practice/your physician is not required to agree to your request for restriction, except for a restriction requested to not disclose information to your health plan for care and services you have paid in full out-of-pocket.
• You have a right to request to receive confidential communications: You have a right to request confidential communications from us by alternative means or at an alternative location. For example, you may designate we send mail only to an address specified by you which may or may not be your home address. You may indicate we should only call you on your work phone or specify which telephone numbers we are allowed or not allowed to leave messages on. You do not have to disclose the reason for your request; however, you must submit a request with specific instructions in writing.
• You have a right to receive a paper copy of this notice: Even if you have agreed to receive an electronic copy of this Privacy Notice, you have the right to request we provide it in paper form. You may make such a request at any time.  
  
  

CHANGES TO THIS NOTICE

We reserve the right to change the terms of this notice and will notify you of such changes. We will also make copies of our new notice available if you wish to obtain one. We will not retaliate against you for filing a complaint.

COMPLAINTS

If you believe your privacy rights have been violated, you can file a complaint in writing with the Privacy Officer. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services at the below address. There will be no retaliation for filing a complaint.

Office for Civil Rights 
Department of HHS 
Jacob Javits Federal Building 
26 Federal Plaza – Suite 3312 
New York, NY 10278 

Voice Phone (212) 264-3313 
FAX (212) 264-3039 
TDD (212) 264-2355 

For Further Information: If you have questions, need further assistance regarding or would like to submit a request pursuant to this Notice, you may contact the Forney Family Dentistry & Orthodontics Privacy Officer by phone at (972) 564-7575 or at the following address: 

108 E US Hwy 80 Ste 190
Forney, TX, 75126

This Notice of Privacy Practices is also available on our Forney Family Dentistry & Orthodontics web page at https://www.forneyfamilydentistry.com.