THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this practice. This notice will tell you about the ways in which I may use and disclose health information about you and your rights to the health information, and describe certain obligations regarding the use and disclosure of your health information. I am required by law to: Make sure that protected health information (“PHI”) that identifies you is kept private. Give this notice of legal duties and privacy practices with respect to health information and follow the terms of the notice that is currently in effect.
II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories. For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider.
MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this practice. This notice will tell you about the ways in which I may use and disclose health information about you and your rights to the health information, and describe certain obligations regarding the use and disclosure of your health information. I am required by law to: Make sure that protected health information (“PHI”) that identifies you is kept private. Give this notice of legal duties and privacy practices with respect to health information and follow the terms of the notice that is currently in effect.
II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories. For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider.
Disclosures for treatment purposes are not limited to the minimum necessary standard. Because other health care providers need access to the full record and/or complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another. Lawsuits and Disputes: If you are involved in a lawsuit, health information may be in response to a court or administrative order. May disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, if efforts have been made to inform or to obtain an order protecting the information requested.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, may use and disclose PHI without your Authorization for the following reasons: When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety. For health oversight activities, including audits and investigations. For judicial and administrative proceedings, including responding to a court or administrative order, although preference is to obtain an Authorization. For law enforcement purposes, including reporting crimes occurring on my premises. To coroners or medical examiners, when such individuals are performing duties authorized by law. For research purposes, Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, may use and disclose PHI without your Authorization for the following reasons: When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety. For health oversight activities, including audits and investigations. For judicial and administrative proceedings, including responding to a court or administrative order, although preference is to obtain an Authorization. For law enforcement purposes, including reporting crimes occurring on my premises. To coroners or medical examiners, when such individuals are performing duties authorized by law. For research purposes, Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States.
Conducting intelligence or counterintelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions. For workers’ compensation purposes to comply with workers’ compensation laws.Appointment reminders and health related benefits or services. To contact you to remind you that you have an appointment. To tell you about treatment alternatives, or other health care services or benefits that I offer.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and reserve the right to decline if it would adversely affect the delivery of care. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way and we will agree to all reasonable requests. The Right to See/Get Copies of Your PHI. Other than “session notes,” you have the right to get an electronic or paper copy of your medical record. Will provide a copy of the record, or a summary, if you agree, within 30 days after request in writing for a reasonable, cost based fee.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and reserve the right to decline if it would adversely affect the delivery of care. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way and we will agree to all reasonable requests. The Right to See/Get Copies of Your PHI. Other than “session notes,” you have the right to get an electronic or paper copy of your medical record. Will provide a copy of the record, or a summary, if you agree, within 30 days after request in writing for a reasonable, cost based fee.
The Right to Get a List of the Disclosures I Have Made: You have the right to request a list of instances of disclosed PHI for purposes other than treatment, payment, or health care operations, or for which you provided Authorization and respond within 60 days of written request and will include disclosures made in the last six years unless request a shorter time. List provided at no charge. More than one request a year will incur a reasonable, cost based fee. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request an amendment, which could be declined, with reasons in writing within 60 days of receiving request. You have the right get a paper copy of this notice or by e-mail. Any other uses and disclosures will be made only with written authorization, which may be revoked in writing at any time my not be retroactive or used where action has been taken in reliance on your authorization, or was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim under the policy or the policy itself.) To exercise your rights under this Notice, receive more information, or to report a problem contact:
HIPAA Compliance Officer
7683 SE 27th St # 294
Mercer Island, WA 98040
Phone: (206) 867-5005
If you believe your privacy rights have been violated, you may file a written complaint with the above individual or the Secretary of Health and Human Services, U.S. Department of Health and Human Services, Washington, D.C. 20201. There will be no retaliation for filing a complaint.
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on October 1, 2024.
Notice Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information.
HIPAA Compliance Officer
7683 SE 27th St # 294
Mercer Island, WA 98040
Phone: (206) 867-5005
If you believe your privacy rights have been violated, you may file a written complaint with the above individual or the Secretary of Health and Human Services, U.S. Department of Health and Human Services, Washington, D.C. 20201. There will be no retaliation for filing a complaint.
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on October 1, 2024.
Notice Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information.