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.
We are required to provide this Notice to you by the Health Insurance Portability and Accountability Act (“HIPAA”). As part of our professional practice, we maintain personal information about you and your health. State and federal laws protect your health 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. You have the following rights regarding PHI we maintain about you:
Right of Access to Inspect and Copy
You have the right, which may be restricted only in certain circumstances, to inspect and copy PHI that we maintain about you. We may charge a reasonable, cost-based fee for copying and transmitting your PHI. To receive a copy of your PHI, you may make a written request to our office.
Right to Amend
If you believe the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are 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 we 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. We are not required to agree to your request.
Right to Request Confidential Communication
You have the right to request that we communicate with you in a certain way or at a certain location. We will accommodate reasonable requests without asking for your rationale.
Right to a Copy of this Notice
You have the right to a copy of this notice.
Right of Complaint
You have the right to file a complaint in writing with Dr. Bart Fowler or with the Secretary of Health and Human Services if you believe we have violated your privacy rights. We will not retaliate against you for filing a complaint.
IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OF PRIVACY PRACTICES, PLEASE CONTACT OUR PRIVACY OFFICER AT
11802 NE 117TH AVENUE, VANCOUVER, WA 98663 (360) 891-2000
Examples of How We May Use and Disclose PHI About You
Listed below are examples of the uses and disclosures that we may make of your protected health information (“PHI”). These examples are not meant to be exhaustive. Rather, they describe types of uses and disclosures that may be made.
Uses and Disclosures of PHI for Treatment, Payment, and Health Care Operations
Treatment. Your PHI may be used and disclosed by us for the purpose of providing you with health care treatment. To coordinate and manage your care, we 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. We may use your PHI in connection with billing statements we send to you. With your authorization, we 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. We may disclose PHI for medical necessity and quality assurance reviews.
Health Care Operations. We may use and disclose, as needed, your PHI for the health care operations of our professional practice in support of the functions of treatment and payment. Such disclosures would be to Business Associates to provide planning, quality assurance, peer review, administrative, legal, or financial services to assist us in the delivery of your health care.
Other Uses and Disclosures Not Requiring Your Authorization or Opportunity to Object
When Required by Law. We 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, notifying appropriate health authorities regarding particular communicable diseases, abuse and neglect reports, law enforcement reports, and reports to coroners and medical examiners in connection with investigation of deaths. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.
For Health Services Oversight . We may disclose your PHI to a health oversight agency for activities authorized by law, such as our professional licensure. Oversight agencies may include government agencies and organizations that audit their provision of financial assistance (such as third-party payers).
Abuse or Neglect . We may disclose your PHI to a state or local agency authorized by law to receive reports of abuse or neglect. The information we disclose is limited to that information which is necessary to make the mandated report.
Threat to Health or Safety. We may disclose PHI when necessary to minimize an imminent danger to the health or safety of you or any other individual.
Criminal Activity on Our Business Premises. We may disclose your PHI to law enforcement officials if you have committed a crime on our premises or against our staff.
Appointment Reminders.We may use your PHI to contact you to remind you of your appointments or for the purposes of rescheduling appointments.
Business Associates. We may disclose your PHI to Business Associates that are contracted by us to perform health care operations or payment activities on our behalf, which may involve their collection, use, or disclosure of your PHI. Our contract with them must require them to safeguard the privacy of your PHI.
Compulsory Process. We will disclose your PHI if a court of competent jurisdiction issues an appropriate order. We will disclose your PHI if (1) we have been notified in writing at least fourteen days in advance of a subpoena or other legal demand, (2) no qualified judicial or administrative order has been obtained, (3) we 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
We may make other uses and disclosures of your PHI with the written authorization of you or your personal representative. You may revoke this authorization in writing at any time, unless we have already taken an action in reliance on the authorization of the use or disclosure you permitted. An example would be continuing to bill for health care services already rendered.
This Notice of Privacy Practices informs you how we may use and disclose your protected health information (“PHI”) and your rights regarding PHI. We are required by law to maintain the privacy of your PHI and to provide you with notice of our legal duties and privacy practices with respect to your PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will make available a revised Notice of Privacy Practices by providing you a copy upon your request, posting it on a web site, and providing a copy to you at your next appointment.
If you believe we have violated your privacy rights, you may file a complaint in writing to our Privacy Officer, specified on the first page of this Notice. We will not retaliate against you for filing a complaint. You may also file a complaint with the U.S. Secretary of the Department of Health and Human Services.