Privacy

Demographic Information: including your name, address, date of birth, phone number(s), name of your employer, your spouse or other family members, and emergency contact.

Insurance Information: including your insurance carrier, the name of the insured person, insurance identification numbers, and benefits and eligibility information.

Health Information: including your health history, past illnesses or injuries, family medical history, your social activities including use of tobacco, alcohol, or drugs, family life and living situation, your current and/or ongoing health problems, including medications, allergies, advised treatment and outcomes of that treatment.

Payment Information: including your insurance carrier, your record of charges, adjustments, and payments to our organization.

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You have the right to inspect and copy your protected health information.

You may inspect and obtain a copy of your protected health information maintained in our office. We may charge you for the cost of copying, mailing or associated supplies.

Under federal law, however, you may not inspect or copy psychotherapy notes or information compiled in reasonable anticipation of a civil, criminal or administrative action or proceeding. Certain documents pertaining to laboratory services are also exempt under federal law.

You have the right to an electronic copy of your records.

You have the right to request your records be sent via e-mail with the understanding that we will try and verify your email before sending. E-mail is not always secure and you are acknowledging this fact. This request must be done in writing.

Under certain circumstances, we may not grant your request. If we deny your request, then you may appeal our decision.

We require that requests to access your protected health information be made in writing. You can arrange to do this through our Privacy Officer.

We require that requests to access your protected health information be made in writing. You can arrange to do this through our Privacy Officer.

You have the right to request a restriction of your protected health information.

You may ask us not to disclose your protected health information for treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to friends and/or family members involved in your care.

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 with emergency care.

In order to request a restriction, you must do so in writing. The request must specifically state what information is restricted and to whom the restriction applies.

You may request a restriction form from our Privacy Officer.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location.

You may request that we communicate with you in a certain way or at a specific location. We will attempt to accommodate all reasonable requests.

Please contact our Privacy Officer to make this request in writing. Your request must specify where or how the communication is to be directed.

You have the right to request that we amend your protected health information.

If you believe that protected health information we have about you is incorrect or incomplete, you may request an amendment to this information.

We may not grant your request if we determine that the protected health information that is the subject of your request:

• Was not created by our organization.
• Is not a part of your medical or billing records.
• Is information that you are not permitted to inspect or copy.
• Is already a complete and accurate record.

Amendment requests must be made in writing and must include a reason for requesting the amendment. If you wish to amend your record, you may contact our Privacy Officer for a form.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

You have the right to receive an accounting of disclosures of protected health information made by us to individuals or entities other than you, except for disclosures:

• To carry out treatment, payment and health care operations as described above
• To persons involved in your care or for other notification purposes as provided by law.
• For national security or intelligence purposes as provided by law.
• To correctional institutions or law enforcement officials as provided by law.
• That occurred prior to April 14, 2003.

You are allowed one free disclosure per each twelve-month period. If you wish additional disclosures within that twelve-month period, we may charge you the cost of providing the disclosure list.

Your request for a disclosure accounting must be made in writing. Please contact our Privacy Officer to obtain a form.

You have the right to file a complaint.

If you believe that your privacy rights have been violated, you have a right to file a complaint in the form of a written letter with our office and with the Secretary of Health and Human Services without fear of retaliation.

A letter of complaint filed with this office should be sent to our Privacy Officer at the address listed below.

Privacy Officer Name: Monica Peay

Address: 11782 SW Barnes Rd #200 Portland, Or 97225

Phone Number: 503-214-5281

You have the right to request and receive a paper copy of this notice from our office.

This Notice is in effect as of September 23, 2013.

We are required to abide by the terms of this Privacy Notice. 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 that time. This notice is in effect as of September 23, 2013. Upon your request, we will provide you with a revised Privacy Notice. You may obtain this by calling our office and requesting that a revised copy be sent to you in the mail, or by asking for one at the time of your next appointment.

Questions/Contact:

If you have questions about this document, or have questions about privacy or patient rights, please contact our Privacy Officer.

Privacy Officer Name: Monica Peay

Address: 11782 SW Barnes Rd #200 Portland, Or 97225

Phone Number: 503-214-5281