1. My Responsibility
The confidentiality of your personal health information is very important to me. Your health information includes records that I create and obtain when I provide you care, such as a record of your symptoms, examination and test results, diagnoses, treatments and referrals for further care. It also includes bills, insurance claims, or other payment information that I maintain related to your care. This Notice describes how I handle your health information and your rights regarding this information. Generally speaking, I am required to:
- Maintain the privacy of your health information as required by law;
- Provide you with this Notice of my duties and privacy practices regarding the health information about you that I collect and maintain;
- Follow the terms of my Notice currently in effect.
2. Contact Information
After reviewing this Notice, if you need further information or want to contact me for any reason regarding the handling of your health information, please direct any communications to my Office Manager at my address or telephone number (see letterhead).
3. Uses and Disclosures of Information
Under federal law, I am permitted to use and disclose personal health information without authorization for treatment, payment, and “health care operations” (certain administrative, financial and legal, and quality improvement activities).
- Example of using or disclosing health information for treatment: I record information about you in your medical record for the purpose of making decisions about your care. I may also provide this information to others who provide care to you to help them stay informed about your care.
- Example of using or disclosing health information for payment: I submit a bill to your health insurer to receive payment for your care; the insurer asks for health information (for example, your diagnosis and what care I provided) in order to pay me. In such situations, I will disclose only the minimum amount of information necessary for this purpose.
- Example of using or disclosing health information for health care operations: I may ask my office personnel to provide information to your pharmacy related to your prescriptions.
4. Other uses and Disclosures
In addition to uses and disclosures related to treatment, payment, and health care operations, I may also use and disclose your personal information without authorization for the following additional purposes:
- Appointment Reminders and Other Health Services: I may use or disclose your health information to reschedule an appointment or to provide you with other information by phone or in writing.
- Business Associates: I may share health information about you with business associates who are performing services such as billing on my behalf. My business associates are obligated to safeguard your health information. I will share with my business associates only the minimum amount of personal health information necessary for them to assist me.
- Communications with Family and Friends: I may disclose information about you to persons who are involved in your care or payment for your care, such as family members, relatives, or close personal friends. Any such disclosure will be limited to information directly related to the person’s involvement in your care. Also, I may notify a family member, your personal representative, or other person responsible for your care, of your location, general condition, or death. If you are available, I will provide you an opportunity to object before disclosing any such information. If you are unavailable because, for example, you are incapacitated or because of some other emergency circumstance, I will use our professional judgment to determine what is in your best interest regarding any such disclosure.
- Personal Representative: I may disclose health information about you to a personal representative authorized to act on your behalf in making decisions about your health care.
- Disaster Relief: I may disclose health information about you to government entities or private organizations (such as the Red Cross) to assist in disaster relief efforts.
- Food and Drug Administration (FDA): I may disclose health information about you to the FDA, or to an entity regulated by the FDA, in order, for example, to report an adverse drug event.
- Required By Law: I may disclose health information about you as required by federal, state, or other applicable law.
- Abuse, Neglect, or Domestic Violence: As required or permitted by law, I may disclose health information about you to a state or federal agency to report suspected abuse, neglect, or domestic violence. If such a report is optional, I will use my professional judgment in deciding whether or not to make such a report. If feasible, I will inform you promptly that I have made such a disclosure.
- Public Health Activities: As required or permitted by law, I may disclose health information about you to a public health authority, for example, to report disease, injury, or vital events such as death. To the extent authorized by law, I may disclose information to a person who may have been exposed to a communicable disease or who is otherwise at risk of spreading a disease or condition.
- Public Safety: Consistent with my legal and ethical obligations, I may disclose health information about you based on a good faith determination that such disclosure is necessary to prevent a serious and imminent threat to the public or to identify or apprehend an individual sought by law enforcement.
- Health Oversight: I may disclose health information about you for oversight activities authorized by law or to an authorized health oversight agency to facilitate auditing, inspection, or investigation related to my provision of health care.
- Judicial or Administrative Proceedings: I may disclose health information about you in the course of a judicial or administrative proceeding, in accordance with my legal obligations.
- Law Enforcement: I may disclose health information about you to a law enforcement official for certain law enforcement purposes. For example, I may report certain types of injuries as required by law, assist law enforcement to locate someone such as a fugitive or material witness, or make a report concerning a crime or suspected criminal conduct.
- Coroners, Medical Examiners, and Funeral Directors: I may disclose health information about you to a coroner or medical examiner, for example, to assist in the identification of a decedent or determining cause of death. I may also disclose health information to funeral directors to enable them to carry out their duties.
- Organ and Tissue Donation: I may disclose health information about you to organ procurement organizations or similar entities to facilitate organ, eye, or tissue donation and transplantation.
- Specialized Government Functions: I may disclose health information about you for certain specialized government functions, as authorized by law. Among these functions are the following: military command; determination of veterans’ benefits; national security and intelligence activities; and protection of the President and other officials.
- Workers’ Compensation: I may disclose health information about you for purposes related to workers’ compensation, as required and authorized by law.
5. Psychotherapy Notes
In the course of your care with me, I may keep “psychotherapy notes” that are kept apart from the rest of your medical record. Psychotherapy notes may be disclosed only after you have given written authorization to do so. (Limited exceptions exist, e.g. in order to prevent harm to yourself or others, and to report child abuse/neglect). You cannot be required to authorize the release of your psychotherapy notes in order to obtain health-insurance benefits for your treatment, or enroll in a health plan. Psychotherapy notes are also not among the records that you may request to review or copy (see discussion of your rights in section VI below). If you have any questions, feel free to discuss this subject with me.
6. Your Health Information Rights
Under the law, you have certain rights regarding the health information that I collect and maintain about you. To exercise any of these rights, you must submit your request in writing to my Office Manager at my address (see letterhead). You have the right to:
- Request that I restrict certain uses and disclosures of your health information; I am not, however, required to agree to a requested restriction.
- Request that I communicate with you by alternative means, such as making records available for pick-up, or mailing them to you at an alternative address. I will accommodate reasonable requests for such confidential communications.
- Request to review, or to receive a copy of, the health information about you that is maintained in my files and the files of my business associates. If I am unable to satisfy your request, I will tell you in writing the reason for the denial and your right, if any, to request a review of the decision.
- Request that I amend the health information about you that is maintained in my files and the files of my business associates. Your request must explain why you believe my records about you are incorrect, or otherwise require amendment. If I am unable to satisfy your request, I will tell you in writing the reason for the denial and tell you how you may contest the decision, including your right to submit a statement disagreeing with the decision. This statement will be added to your records.
- Request a list of my disclosures of your health information. This list, known as an “accounting” of disclosures, will not include certain disclosures, such as those made for treatment, payment, or health care operations. I will provide you the accounting free of charge, however if you request more than one accounting in any 12 month period, I may impose a fee for any subsequent request. Your request should indicate the period of time in which you are interested. I will be unable to provide you an accounting for any disclosures made before April 14, 2003 or for a period of longer than six years.
- Request a paper copy of this Notice.
7. To Request Information or File a Complaint
If you believe your privacy rights have been violated, you may file a written complaint by mailing it or delivering it to my Office Manager at my address (see letterhead). You may complain to the U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington, D.C. 20201, or the Washington State Department of Health, 510 4th Avenue West, Suite 404, Seattle, WA 98119. I cannot, and will not, make you waive your right to file a complaint with these agencies as a condition of receiving care from me, or penalize you for filing such a complaint.
8. Revisions to this Notice
I reserve the right to amend the terms of this Notice. If this Notice is revised, the amended terms shall apply to all health information that I maintain, including information about you collected or obtained before the effective date of the revised Notice. If the revisions reflect a material change to the use and disclosure of your information, your rights regarding such information, my legal duties, or other privacy practices described in the Notice, I will promptly distribute the revised Notice and make copies available to my patients.
- Effective Date of this Notice: April 14, 2003