Your Information. Your Rights. Our Responsibilities
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
You have the right to:
You have some choices in the way that we use and share information as we:
Our Uses and Disclosures
We may use and share your information as we:
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
Ask us to correct your medical record
We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Request confidential communications
Ask us to limit what we use or share
Get a list of those with whom we’ve shared information
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
File a complaint if you feel your rights are violated
I am licensed in Washington State as a ___________________ License Number _______________.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
In these cases we never share your information unless you give us written permission:
In the case of fundraising:
Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
Treat you. We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization. We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
Bill for your services. We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as:
Do research. We can use or share your information for health research.
Comply with the law. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests. We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director. We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests. We can use or share health information about you:
Respond to lawsuits and legal actions. We can share health information about you in response to a court or administrative order, or in response to a subpoena.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all the information we have about you. The new notice will be available upon request, in our office, and on our web site.
Other Instructions for Notice
The Privacy Rule requires that we describe Washington State laws that may invoke limits on confidentiality or disclosure of information. Those laws are described in the disclosure form that accompanies this Notice. In short, we are required by State law to disclose information regarding the abuse or neglect of a child or of a vulnerable adult. We have a duty to warn / protect others, if a client has communicated an actual threat of physical harm against an identifiable person. Disclosure of PHI may be required by subpoena or court order. Disclosure to any person may be permitted if we have a reasonable belief that doing so will avoid imminent danger or harm to any person.