NOTICE OF PRIVACY PRACTICES
This notice describes how medical information about you may be used and
and how you can get access to this information
PLEASE READ CAREFULLY
If you have any questions about this notice, please contact the Privacy
Officer of our office
at 503.639.6002 x104, 15755 SW Sequoia Pkwy, Suite 200, Tigard, Oregon
WHO WILL FOLLOW THIS NOTICE?
This notice describes the information privacy practices followed by our
employees, staff and other office personnel. The practices described in
this notice will also be followed by physicians you consult by telephone
(when your regular physician from our office is not available) who provide
“call coverage for your physician.
YOUR HEALTH INFORMATION
This notice applies to the information and records we have about your
health, health status, and the healthcare and services you receive at
We are required by law to give this notice. It will tell you about the
ways in which we may use and disclose health information about you, and
describes your rights and our obligations regarding the use and disclosure
of that information.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
We must have your written, signed CONSENT to use and disclose health information
for the following purposes:
For Treatment: We may use health information about you to provide you
with medical treatment or services.
We may disclose health information about you to doctors, nurses, technician,
office staff or other personnel who are involved in taking care of you
and your health.
For example, your doctor may be treating you for a heart condition and
may need to know if you have other health problems that could complicate
your treatment. The doctor may use your medical history to decide what
treatment is best for you. The doctor may also tell another doctor about
your condition so that doctor can help determine the most appropriate
care for you.
Different personnel in our office may share information about you and
disclose information to people who do not work in our office in order
to coordinate your care, such as phoning in prescriptions to your pharmacy,
scheduling lab work and ordering x-rays. Family members and other healthcare
providers may be part of your medical care outside this office and may
require information about you that we have.
For Payment: We may use and disclose health information about you so that
the treatment and services you receive at this office may be billed to
and payment may be collected from you, an insurance company or a third
For example, we may need to give your health plan information about a
service you received here so that your health plan will pay us or reimburse
you for the service. We may also tell your health plan about a treatment
you are going to receive to obtain prior approval, or to determine whether
your plan will cover treatment.
For Healthcare Operations: We may use and disclose health information
about you in order to run the office and make sure that you and our other
patients receive quality care.
For example, we may use your health information to evaluate the performance
of our staff in caring for you. We may also use health information about
all or many of our patients to help us decide what additional services
we should offer, how we can become more efficient, and whether certain
new treatments are effective.
Appointment Reminders: We may contact you as a reminder that you have
an appointment for treatment or medical care at this office.
Treatment Alternatives: We may tell you about or recommend possible treatment
options or alternatives that may be of interest to you.
Please notify us if you do not wish to be contacted for appointment reminders,
or if you do not wish to receive communications about treatment alternatives
or health-related products. If you advise us in writing (at the address
show at the top of this Notice) that you do not wish to receive such communications,
we will not use or disclose your information for these purposes.
You may revoke your CONSENT at any time by giving us written notice. Your
revocation will be effective when we receive it, but it will not apply
to any uses and disclosures which occurred before that time. If you do
revoke your CONSENT, we will not be permitted to use or disclose your
information for purposes of treatment, payment or healthcare operations,
and we may therefore choose to discontinue providing you with healthcare
treatment and services. SPECIAL SITUATIONS
We may use and disclose health information about you without your permission
for the following purposes, subject to all applicable legal requirements
Required by Law: We will disclose health information about you when required
to do so by federal, state or local law.
To Avert a Serious Threat to Health or Safety: We may use and disclose
health information about you when necessary to prevent a serious threat
to your health and safety or the health and safety of the public or another
Public Health Risks: We may disclose health information about you for
public health reasons in order to prevent or control disease, injury or
disability; or report births, deaths, suspected abuse or neglect, nonaccidental
physical injuries, reactions to mediations or problems with products.
Workers' Compensation: We may release health information about you for
workers' compensation or similar programs. These programs offer benefits
for work-related injuries or illness.
Health Oversight Activities: We may disclose health information to a health
oversight agency for audits, investigations, inspections, or licensing
purposes. These disclosures may be necessary for certain state and federal
agencies to monitor the healthcare system, government programs, and compliance
with civil rights laws.
Lawsuits and Disputes: If you are involved in a lawsuit or dispute, we
may disclose health information about you in response to a court order,
subpoena, warrant, summons or similar process, subject to all applicable
Information Not Personally Identifiable: We may use or disclose health
information about you in a way that does not personally identify you or
reveal who you are.
Research: We may use and disclose health information about you for research
projects that are subject to a special approval process. We will ask you
for your permission if the researcher will have access to your name, address,
or other information that reveals who you are, or will be involved in
your care at the office.
Family and Friends: We may disclose information about you to your family
members or friends if we obtain your verbal agreement to do so or if we
give you an opportunity to object to such a disclosure and you do not
raise an objection. We may also disclose health information to your family
and friends if we can infer from the circumstances, based on our professional
judgment that you would not object. For example, we may assume you agree
to our disclosure of your personal health information to your spouse when
you bring your spouse with you into an exam room during treatment or while
treatment is discussed.
In situations where you are not capable of giving consent (because you
are not present or due to your incapacity or medical emergency), we may,
use our professional judgment, determine that a disclosure to your family
member or friend is in your best interest. In that situation, we will
disclose only health information relevant to the person's involvement
in your care. For example, we may inform the person who accompanied you
to the emergency room that you suffered a heart attack and provide updates
on your progress and prognosis. We may also use our professional judgment
and experience to make reasonable inference that it is in your best interest
to allow another person to act on your behalf to pick up, for example,
filled prescriptions, medical supplies or x-rays.
Military, Veterans, National Security and Intelligence: If you are or
were a member of the armed forces, or part of the national security or
intelligence communities, we may be required by military command or other
government authorities to release health information about you. We may
also release information about foreign military personnel to the appropriate
foreign military authority.
Law Enforcement: We may disclose your health information in response to
a request received from a law enforcement official to report criminal
activity or to respond to a subpoena, court order, warrant, summons, or
Inmates. If you are an inmate of a correctional institution or under the
custody of a law enforcement official, we may use or disclose your health
information to the correctional institution or to the law enforcement
official as may be necessary (i) for the institution to provide you with
health care; (ii) to protect the health or safety of you or another person;
or (iii) for the safety and security of the correctional institution.
OTHER USES AND DISCLOSURES OF HEALTH INFORMATION
We will not use or disclose your health information for any purpose other
than those identified in the previous sections without your specific,
written AUTHORIZATION, separate from any CONSENT we may have obtained
from you. If you give us AUTHORIZATION to use or disclose health information
about you, you may revoke that AUTHORIZATION, in writing, at any time.
If you revoke your AUTHORIZATION, we will no longer use or disclose information
about you for the reasons covered by your written AUTHORIZATION but we
cannot take back any uses or disclosures already made with your permission.
If we have HIV or substance abuse information about you, we cannot release
that information without a special signed, written authorization (difference
from the AUTHORIZATION and CONSENT mentioned above) from you. In order
to disclose these types of records for purposes of treatment, payment
or healthcare operations, we will have to have both your signed CONSENT
and a special written authorization that complies with the law governing
HIV or substance abuse records.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
You have the following rights regarding health information we maintain
Right to Inspect and Copy: You have the right to inspect and copy your
health information, such as medical and billing records, that we use the
make decisions about your care. Your must submit a written request to
the Privacy Officer, 15755 SW Sequoia Pkwy, Suite 200, Tigard, Oregon
97224, in order to inspect and / or copy your health information. If you
request a copy of the information, we may charge you a fee for the costs
of the copying, mailing or other associated supplies. We have 30 days
to comply with a request for all copied records, but will try to get records
out in a reasonable timeframe.
We may deny your request to inspect and / or copy in certain limited circumstances.
If you are denied access to your health information, you may ask that
the denial be reviewed. If such a review is required by law, we will select
a licensed healthcare professional to review your request and our denial.
The person conducting the review will not be the person who denied your
request, and we will comply with the outcome of the review.
Right to Amend: If you believe health information we have about you is
incorrect or incomplete, you may ask us to amend the information. You
have the right to request an amendment as long as the information is kept
by this office.
To request an amendment, complete and submit a MEDICAL RECORD AMENDMENT
/ CORRECTION FORM to the Privacy officer, 15755 SW Sequoia Pkwy, Suite
200, Tigard, Oregon 97224.
We may deny your request for an amendment if it is not in writing or does
not include a reason to support the request. In addition, we may deny
your request if you ask us to amend information that:
:: We did not create, unless the person or entity that created the information
is no longer able to make that amendment.
:: Is not part of the health information that we keep.
:: You would not be permitted to inspect and copy.
:: Is accurate and complete.
Right to an Accounting of Disclosures: You have the right to request an
accounting of disclosures. This is a list of disclosures we have made
of medical information about you for purposes other than treatment, payment
or healthcare operations.
Right to Request Restrictions: You have the right to request a restriction
or limitation on the health information we use or disclose about you for
treatment, payment or healthcare operations. You also have the right to
request a limit on the health information we disclose about you to someone
who is involved in your care or the payment for it, like a family member
or friend. For example, you could ask that we not use or disclose information
about a surgery you had.
We are not required to agree to your request. If we do agree, we will
comply with your request unless the information is needed to provide you
To request restrictions, you may complete and submit the REQUEST FOR RESTRICTION
ON USE / DISCLOSURE OF MEDICAL INFORMATION to the Privacy Officer, 15755
SW Sequoia Pkwy, Suite 200, Tigard, Oregon 97224.
Right to a Paper Copy of This Notice: You have the right to ask us for
a paper copy of this Notice at any time. Even if you have agreed to receive
it electronically, you are still entitled to a paper copy.
To obtain a paper copy, contact the Privacy Officer at 503.639.6002 x104,
15755 SW Sequoia Pkwy, Suite 200, Tigard, Oregon 97224.
CHANGES TO THIS NOTICE
We reserve the right to change this Notice, and to make the revised Notice
effective for medical information we already have about you as well as
any information we receive in the future. We will post a summary of the
current Notice in the office with its effective date in the top righthand
corner. You are entitled to a copy of the Notice currently in effect.
If you believe your privacy rights have been violated, you may file a
complaint with our office or with the Secretary of the Department of Health
and Human Services. To file a complaint with our office, contact the Privacy
Officer at 503, 639.6002, 15755 SW Sequoia Pkwy, Suite 200, Tigard, Oregon
97224. You will not be penalized for filing a complaint.