Notice of Patient Privacy (Long Form)
Health Insurance Portability and Accountability Act (HIPAA)
Effective Date: March 3, 2013 Updated: March 24, 2022
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.
If you have any questions about this notice please contact:
The WellBridge Clinic
(503) 544-9611
frontdesk@WellBridgeClinic.Com
This notice of Privacy Practices describes how me may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, which may identify you and which relates to your past, present or future physical or mental health or condition and related healthcare services.
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at the time. Upon your request, we will provide you with any revised Notice of Privacy Practices by calling he office and requesting
that a revised copy be sent to you in the mail or asking for one at the time of your next appointment
1. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
Uses and Disclosures of Protected Health Information
The WellBridge Clinic will use and disclose your protected health information for treatment, payment and health care operations (TPO). Your doctor will use and disclose your protected health information as described in section 1.
Your protected health information may be used and disclosed by your doctor, our office staff and others outside ofour office that are involved in your care and treatment for the purpose of providing healthcare services to you. Your protected heath information may also be used and disclosed to pay your healthcare bills and to support the operation
of the doctor’s practices.
Following are examples of the types of uses and disclosures of your protected health care information that the doctor’s office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.
Treatment: We will use and disclose your protected health information to provide, coordinate or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party that has already obtained your permission to have access to your protected health information. For example,
we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other healthcare providers who may be treating you or whom you may be referred, or for consultation purposes. For example, your protected health information may be
provided to another healthcare provider to whom you have been referred to ensure that the healthcare provider has the necessary information to diagnose or treat you. All protected health information provided will be based on the “minimum amount necessary” and still be able to provide appropriate care.
In addition, we may disclose your protected health information from time to time to another care provider who, at the request of your healthcare provider, becomes involved in your care by providing assistance with your healthcare diagnosis or treatment to your healthcare provider.
Payment: Your protected health information will be used, as needed, to obtain payment for your healthcare services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the healthcare services, we recommend for you such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant health information be disclosed to the health plan to obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your doctor’s practice. These activities include, but ae not limited to, quality assessment activities, employee review activities, training of medical students, licensing, marketing and fundraising activities,
and conducting or arranging for other business activities.
For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate which provider you will be seeing. We may also call you by name in the waiting room when your
doctor is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
We will share your protected health information with third party “business associates” that will perform various activities (e.g. billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written
contract that contains terms that will ensure the pr4ivacy of your protected health information.
We may use or disclose your protected health information, as necessary to provide you with the information about your treatment alternatives or other health-related benefits and services that may be of interest to you. We may also use and disclose your protected health information for other marketing activities. For example, your name and
address may be used to send you a newsletter about our practice and the services we offer. We may also send you information about products and services that we believe may be beneficial to you. You may contact our Privacy Officer to request that these materials not be sent to you.
We may use or disclose your demographic information and the dates that you received treatment from your healthcare provider, as necessary, in order to contact you for fundraising activities supported by our office. If you do not want to receive these materials, please contact our Privacy Officer and request that these fundraising materials
not be sent to you.
Uses and Disclosures of Protected Health Information Based upon Your Written Authorization
Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that your healthcare provider or clinic has taken action in reliance on the use or
disclosure indicated in the authorization
Other Permitted and Required Uses and Disclosure that may be Made With Your Consent, Authorization or Opportunity to Object
We may use and disclose your protected heath information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your healthcare provider
may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your healthcare will be disclosed.
Facility Directories: Unless you otherwise object we will use and disclose in our facility directory your name, the location at which you are receiving care, your condition (in general terms), and your religious affiliation. All of this information, except religious affiliation, will be disclosed to people that ask for you by name. Members of the clergy will be told your religious affiliation. (this section will only be applicable to larger practices that operate facilities)
Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use
or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosure to family or other individuals involved in your healthcare.
Emergencies: We may use or disclose your protected health information in an emergency treatment situation. If this happens, your doctor shall try to obtain your consent as soon as reasonably practicable after the delivery of the treatment. If your doctor or another doctor in the practice is required by law to treat you and the doctor has attempted to obtain your consent, he or she may still use or disclose your protected health information to treat you.
Communication Barriers: We may use and disclose your protected health information if your doctor or another healthcare provider in the practice attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the doctor determines, using professional judgment, that you intend to consent to use or disclosure under the circumstances.
Other Permitted and Required Uses and Disclosures That May be Made Without your Consent, Authorization or Opportunity to Object
We may use or disclose your protected health information in the following situations without your consent or
authorization. These include:
Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.
Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.
Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the healthcare system, government benefit programs, other government regulatory programs and civil rights laws.
Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition we may disclose your protected health information if we believe that you have been the victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post
marketing surveillance, as required.
Legal Proceedings: We may disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal process and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of
a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred.
Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.
Research: We may disclose protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to endure the privacy of your protected health information.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health and safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary b appropriate command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally
authorized.
Worker’s Compensation: Your protected health information may be disclosed by us as authorized to comply with worker’s compensation laws and other similar legally-established programs.
Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your doctor created or received your protected health information in the course of providing care to you.
Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500et.seq.
2. YOUR RIGHTS
Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that your doctor and the practice use for making decisions about you
Under federal law, however, you may not inspect a copy of the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in a, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you
have any questions about access to your medical records.
You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that nay part of your protected health information no to be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
Your doctor/healthcare provider is not required to agree to a restriction that you may request. If your doctor/healthcare provider believes it is in your best interest to permit use and disclosure of your protected health
information, your protected health information will not be restricted. If your doctor/healthcare provider does not agree to the requested restriction, we may not use or disclose your protected health information without being in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you with to request, in writing, with the Privacy Officer, John Rybak.
You have the right to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact.
We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer, John Rybak.
You have the right to request that your doctor amend your protected health information. This mean you may request an amendment of your protected health information in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Any request for an amendment must be in writing. Please contact our Privacy Officer, John Rybak.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after November 15, 2018. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations.
You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.
3. COMPLAINTS
You may file a complaint with us by notifying our Privacy Officer, John Rybak of your complaint. All complaints must be in writing. If you are not satisfied with the resolution of your complaint and believe your privacy rights have been violated by us you may contact the Secretary of Health and Human Services. They can be contacted at the Department of Health and Human Services; 200 Independence Ave. SW; Washington DC 20201. Their phone number is toll free, 1-877-693-6775. We will not retaliate against you for filling a complaint.
You may contact our Privacy Officer, Clinic Director John Rybak at (503) 544-9611 for further information about the complaint process.
This notice was published and becomes effective on November 15, 2018.