Essential Direct Primary Care
405 Black Hills Ln
SW, Ste B2
Olympia, WA 98502
(360) 688-1151
NOTICE OF
PRIVACY PRACTICES
Your Information. Your Rights. Our Responsibilities.
THIS
NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS PRACTICE)
MAY BE USED AND DISCLOSED, AND HOW YOU CAN GAIN ACCESS TO YOUR INDIVIDUALLY
IDENTIFIABLE HEALTH INFORMATION.
PLEASE
REVIEW THIS NOTICE CAREFULLY.
A. OUR COMMITMENT TO YOUR PRIVACY:
Our practice is dedicated to
maintaining the privacy of your individually identifiable health information
(IIHI). In conducting our business, we will create records regarding you and
the treatment and services we provide to you. We strive to maintain the confidentiality
of health information that identifies you. This notice explains the privacy practices
that we maintain in our practice concerning your IIHI.
The terms of this notice apply to
all records containing your IIHI that are created or retained by our practice.
We reserve the right to revise or amend this Notice of Privacy Practices. Any
revision or amendment to this notice will be effective for all of your records
that our practice has created or maintained in the past, and for any of your
records that we may create or maintain in the future. You may request a copy of
our most current Notice at any time.
B. IF YOU HAVE QUESTIONS ABOUT
THIS NOTICE, PLEASE CONTACT:
Essential Direct Primary Care
Attn: Privacy Officer
405 Black Hills Ln SW, Ste B2
Olympia, WA 98502
(360) 688-1151
C. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY
IDENTIFIABLE HEALTH INFORMATION (IIHI) IN THE FOLLOWING WAYS:
The following categories describe
the different ways in which we may use and disclose your IIHI, unless you
object:
1. Treatment. Our practice may use your IIHI to
treat you. For example, we may ask you to have laboratory tests (such as blood
or urine tests), and we may use the results to help us reach a diagnosis. We
might use your IIHI in order to write a prescription for you, or we might
disclose your IIHI to a pharmacy when we order a prescription for you. Our
staff may use or disclose your IIHI in order to treat your or to assist others
in your treatment. Additionally, we may disclose your IIHI to others who may
assist in your care, such as other healthcare providers, your spouse, your
children or your parents.
2. Payment. Our practice may use and disclose
your IIHI in order to bill and collect payment for the services and items you
may receive from us. We do not accept or bill insurance, so we do not disclose
your information for the purpose of being reimbursed by insurance. However, we
may use and disclose your IHII to obtain payment from those that may be
responsible for such costs, such as family members. Also, we may use your IIHI
to bill you directly for services and items.
3. Health Care Operations. Our practice may use and disclose
your IIHI to operate our business. As examples of the ways in which we may use
and disclose your information for our operations, our practice may use your
IIHI to evaluate the quality of care you received from us, to develop protocols
and clinical guidelines, to develop training programs, and to aid in
credentialing, medical review, legal services and insurance. We will share
information about you with such insurers or other business associates as
necessary to obtain these services.
4. Appointment Reminders. Our practice may use and disclose
your IIHI to contact you and remind you of an appointment.
5.
Treatment Options. Our practice may use and disclose your IIHI to
inform you of
potential treatment options or alternatives.
6.
Health-Related Benefits and Services. Our practice may use and disclose your IIHI to inform you of
health-related benefits or services that may be of interest to you.
7. Release of Information to
Family/Friends.
Our practice may release your IIHI when necessary, to a friend or family member
that is involved in your care, or who assists in taking care of you. For example,
a parent or guardian may ask that a babysitter take their child to the pediatrician’s
office for treatment of a cold. In this example, the babysitter may have access
to this child’s medical information.
8. Disclosures Required by Law. Our practice will use and
disclose your IIHI when we are required to do so by federal, state, or local
law or regulation.
D. USE AND DISCLOSURE OF YOUR IIHI
IN CERTAIN SPECIAL CIRCUMSTANCES:
The following categories describe
unique scenarios in which we may use or disclose your identifiable health
information: by law to collect information for the purpose of:
1. Public Health Risks. Our practice may disclose your IIHI to public health authorities that are authorized by law to collect information for the purpose of:
- maintaining vital records, such as births and deaths
- reporting child abuse or neglect
- preventing or controlling disease, injury, or disability
- notifying a person regarding potential exposure to a communicable disease
- notifying a person regarding a potential risk for spreading or contracting a disease or condition
- reporting reactions to drugs or problems with products or devices
- notifying individuals if a product or device they may be using has been recalled
- notifying appropriate government agency (ies) and authority (ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information
- notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance
2. Health Oversight Activities. Our practice may disclose your
IIHI to a health oversight agency for activities authorized by law. Oversight
activities can include, for example, investigations, inspections, audits,
surveys, licensure and disciplinary actions; civil, administrative, and
criminal procedures or actions; or other activities necessary for the
government to monitor government programs, compliance with civil rights laws
and the health care system in general.
3. Lawsuits and Similar Proceedings. Our practice may use and disclose
your IIHI in response to a court or administrative order, if you are involved
in a lawsuit or similar proceeding. We also may disclose your IIHI in response
to a discovery request, subpoena, or other lawful process by another party
involved in the dispute, but only if we have made an effort to inform you of
the request or to obtain an order protecting the information the party has
requested.
4. Law Enforcement. We may release IIHI if required to do so by a law enforcement official:
- regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement
- concerning a death we believe has resulted from criminal conduct
- regarding criminal conduct at our offices
- in response to a warrant, summons, court order, subpoena or similar legal process
- to identify/locate a suspect, material witness, fugitive or missing person
- in an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator)
5. Deceased Patients. Our practice may release IIHI to
a medical examiner or coroner to identify a deceased individual or to identify
the cause of death. If necessary, we may also release information in order for
funeral directors to perform their jobs.
6. Organ and Tissue Donation. Our practice may release your
IIHI to organizations that handle organ, eye or tissue procurement or
transplantation, including organ donation banks, as necessary to facilitate
organ or tissue donation and transplantation if you are an organ donor.
7.
Research. Our practice may use and disclose your IIHI for
research purposes in certain
limited circumstances. We will obtain your written authorization to use your IIHI for research
purposes except when: (a) our use or disclosure was approved by an
Institutional Review Board or a Privacy Board; (b) we obtain the oral or written agreement
of a researcher that (i) the information being sought is necessary for the research
study; (ii) the use or disclosure of your IIHI is being used only for the research
and (iii) the researcher will not remove any of your IIHI from our practice; or
(c) the IIHI sought by the researcher only relates to decedents and the
researcher agrees either orally or in writing that the use or disclosure is necessary
for the research and, if we request it, to provide us with proof of death prior to
access to the IIHI of the decedents
8. Serious Threats to Health or
Safety. Our
practice may use and disclose your IIHI when necessary to reduce or prevent a
serious threat to your health and safety or the health and safety of another
individual or the public. Under these circumstances, we will only make
disclosures to a person or organization able to help prevent the threat.
9. Military. Our practice may disclose your
IIHI if you are a member of U.S. or foreign military forces (including
veterans) and if required by the appropriate authorities.
10.
National Security. Our practice may disclose your IIHI to federal
officials for intelligence
and national security activities authorized by law. We may also disclose your IIHI to
federal officials in order to protect the President, other officials or foreign heads
of state, or to conduct investigations.
11.
Inmates. Our practice may disclose your IIHI to
correctional institutions or law
enforcement officials if you are an inmate or under the custody of a law enforcement official.
Disclosure for these purposes would be necessary: (a) for the institution to provide
health care services to you, (b) for the safety and security of the
institution, and/or (c) to protect your health and safety or the health and safety of other
individuals.
12. Workers’ Compensation. Our practice may release your
IIHI if required for workers’ compensation and similar programs.
E. YOUR RIGHTS REGARDING YOUR
IIHI:
The health and billing records we
maintain are the physical property of Essential Direct Primary Care. The
information in it, however, belongs to you. You have a right to:
1. Confidential Communications. You have the right to request
that our practice communicate with you about your health and related issues in
a particular manner or at a certain location. For instance, you may ask that we
contact you at home, rather than work. In order to request a type of
confidential communication, you must make a written request to the Privacy
Officer, specifying the requested method of contact, or the location where you
wish to be contacted. Our practice will accommodate reasonable requests. You do
not need to give a reason for your request.
2. Requesting Restrictions. You have the right to request a
restriction in our use or disclosure of your IIHI for treatment, payment or
health care operations. Additionally, you have the right to request that we
restrict our disclosure of your IIHI to only certain individuals involved in
your care or the payment for your care, such as family members and friends. We
are not required to agree to your request; however, if we do agree, we are
bound by our agreement except when otherwise required by law, in emergencies, or
when the information is necessary to treat you. In order to request a
restriction in our use or disclosure of your IIHI, you must make your request
in writing to the Privacy Officer. Your request must describe in a clear and
concise fashion:
(a) the information you wish restricted;
(b) whether you are requesting to limit our practice’s use, disclosure, or
both; and
(c) to whom you want the limits to apply.
3. Inspection and Copies. You have the right to inspect and
obtain a copy of the IIHI that may be used to make decisions about you,
including patient medical records and billing records, but not including
psychotherapy notes. You must submit your request in writing to the Privacy
Officer in order to inspect and/or obtain a copy of your IIHI. Our practice may
charge a fee for the costs of copying, mailing, labor and supplies associated with
your request. Our practice may deny your request to inspect and/or copy in
certain limited circumstances; however, you may request a review of our denial.
Another licensed health care professional chosen by us will conduct reviews.
4. Amendment. You may ask us to amend your
health information if you believe it is incorrect or incomplete, and you may
request an amendment for as long as the information is kept by or for our
practice. To request an amendment, your request must be made in writing and
submitted to the Privacy Officer. You must provide us with a reason that
supports your request for amendment. Our practice will deny your request if you
fail to submit your request (and the reason supporting your request) in
writing. Also, we may deny your request if you ask us to amend information that
is in our opinion: (a) accurate and complete; (b) not part of the IIHI kept by
or for the practice; (c) not part of the IIHI which you would be permitted to
inspect and copy; or (d) not created by our practice, unless the individual or
entity that created is not available to amend the information.
5. Right to a Paper Copy of this
Notice. You may
receive a paper copy of our notice of privacy practices. You may ask us to give
you a copy of this notice at any time. To obtain a paper copy of this notice,
contact the Privacy Officer.
6. Right to File a Complaint. If you believe your privacy
rights have been violated, you may file a complaint with our practice. To file
a complaint with our practice, contact:
Essential Direct Primary Care
Attn: Privacy Officer
405 Black Hills Ln SW, Ste B2
Olympia, WA 98502
(360) 688-1151
All complaints must be submitted
in writing. You will not be penalized for filing a complaint.
7. Right to Provide an
Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization
for uses and disclosures that are not identified by this notice or permitted by
applicable law. Any authorization you provide to us regarding the use and
disclosure of your IIHI may be revoked at any time in writing. After you revoke
your authorization, we will no longer use or disclose your IIHI for the reasons
described in the authorization. Please note: we are required to retain records
of your
care.
Again, if you have questions
regarding this notice or our health information privacy policies, please
contact the Privacy Officer listed above.
Acknowledgement
I hereby acknowledge that I have received and read Essential Direct Primary Care’s Notice of Privacy Practices. I understand that I may request additional copies of this notice at any time.
By providing my electronic signature, I agree that it will represent my signature—just the same as a pen-and-paper signature—for all purposes when I (or my agent) use them on documents, including legally binding contracts.
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