NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
As part of my professional practice, I maintain personal information about you and your health. State and federal law protects such information by limiting its uses and disclosures. “Protected health information”
(“PHI”) is information about you, including demographic information, that may identify you or be used to identify you, and that relates to your past, present or future physical or mental health or condition, the provision of health care services, or the past, present or future payment for the provision of health care.
Your Rights Regarding Your PHI. The following are your rights regarding PHI I maintain about you:
Right of Access to Inspect and Copy. You have the right, which may be restricted only in certain limited circumstances, to inspect and copy your PHI that I maintain, including any PHI held electronically. I may charge a reasonable, cost-based fee for copies.
Right to Amend. If you feel that the PHI I have about you is incorrect or incomplete, you may ask me to amend the information although I am not required to agree to the amendment.
Right to an Accounting of Disclosures. You have the right to request a copy of the required accounting of disclosures that I make of your PHI.
Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. I am not required to agree to your request. You have the right to restrict disclosure of your PHI to a health plan when you have paid out of pocket for the health service.
Right to Request Confidential Communication. You have the right to request that I communicate with you in a certain way or at a certain location. I will accommodate reasonable requests and will not ask why you are making the request.
Right to a Copy of this Notice. You have the right to a paper copy of this notice.
Right to Opt Out. I do not do any fundraising activity. You have the right to opt out of any fundraising communications.
Right to Notification. You have the right to be notified if there has been a breach of your PHI.
Right of Complaint. You have the right to file a complaint in writing with me or with the Secretary of Health and Human Services if you believe I have violated your privacy rights. I will not retaliate against you for filing a complaint, [unless the disclosure was generated by illegal behavior on your part, such as hacking.]
My Uses and Disclosures of PHI for Treatment, Payment and Health Care Operations.
Treatment. I may use your PHI for the purpose of providing you with health care treatment. To coordinate and manage your care, I may disclose your PHI to others of your current providers, and to the extent you have not raised an objection in writing, to your prior providers, or to other persons, including family members, involved in your care.
Payment. I may use your PHI in connection with billing statements I send you and my system for tracking charges and credits to your account. In addition, but with your authorization, I may disclose your PHI to third party payers to obtain information concerning benefit eligibility, coverage, and remaining availability, as well as to submit claims for payment and to disclose PHI for medical necessity and quality assurance reviews.
Notice of Privacy Practices – October 2013
Health Care Operations. I may use and disclose your PHI for the health care operations of my professional practice in support of the functions of treatment and payment. Such disclosures would be to Business Associates for health care education, or to provide planning, quality assurance, peer review, administrative, legal, or financial services to assist me in my delivery of your health care. In the event of my unexpected death or disability, colleagues will be authorized to provide administrative, legal, financial services to manage my business and facilitate the continuation of your health care with another provider. They will have access to your PHI in order to contact you and assist you in finding a new care provider. They will observe all of my privacy practices and ensure your confidentiality is maintained as appropriate and legally required. I will not make any uses or disclosures of your PHI for marketing purposes nor sell your PHI without authorization.
Other Uses and Disclosures That Do Not Require Your Authorization or Opportunity to Object Required by Law. I may use or disclose your PHI to the extent that the use or disclosure is required by law, made in compliance with the law, and limited to the relevant requirements of the law.
Examples are public health reports, abuse and neglect reports, law enforcement reports, and reports to coroners and medical examiners in connection with investigation of deaths. I also must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining my compliance with the requirements of the Privacy Rule.
Health Oversight. I may disclose your PHI to a health oversight agency for activities authorized by law, such as my professional licensure. Oversight agencies also include government agencies and organizations that audit their provision of financial assistance to me (such as third-party payers).
Threat to Health or Safety. I may disclose your PHI when necessary to minimize an imminent danger to the health or safety of you or any other individual.
Appointment Reminders. I may use your PHI to contact you to remind you of your appointments with me.
Business Associates. I may disclose your PHI to Business Associates that are contracted by me to perform health care operations or payment activities on my behalf which may involve their collection, use or disclosure of your PHI. My contract with them must require them to safeguard the privacy of your PHI.
Compulsory Process. I will disclose your PHI if a court of competent jurisdiction issues an appropriate order. I will also disclose your PHI if (1) you and I have each been notified in writing at least fourteen days in advance of a subpoena or other legal demand, identifying the PHI sought, and the date by which a protective order must be obtained to avoid my compliance, (2) no qualified judicial or administrative protective order has been obtained, (3) I have received satisfactory assurances that you received notice of an opportunity to have limited or quashed the discovery demand, and (4) such time has elapsed.
Uses and Disclosures of PHI With Your Written Authorization
I will make other uses and disclosures of your PHI only with your written authorization. You may revoke this authorization in writing at any time, unless I have taken an substantial action in reliance on the authorization such as providing you with health care services for which I must submit subsequent claim(s) for payment.
This Notice of Privacy Practices informs you how I may use and disclose your protected health information (“PHI”) and your rights regarding your PHI. I am required by law to maintain the privacy of your PHI and to provide you with notice of my legal duties and privacy practices with respect to your PHI. I am required to abide by the terms of this Notice of Privacy Practices. I reserve the right to change the terms of my Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. I will make available a revised Notice of Privacy Practices by providing you a copy upon your request, or providing a copy to you at your next appointment.
I am my own Privacy Officer, so, if you have any questions about this Notice of Privacy Practices, please contact me.
My contact information is:
2611 3rd Ave. W.
Seattle, WA 98119
If you believe I have violated your privacy rights, you may file a complaint in writing to me, as my own Privacy Officer, specified on the first page of this Notice. I will not retaliate against you for filing a complaint. You may also file a complaint with the Secretary of the Department of Health and Human Services.
The effective date of this Notice is October 9, 2013.
I hereby acknowledge receiving a copy of this notice.
Patient’s Signature Date