NOTICE OF PRIVACY PRACTICES
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.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also
required to give you this Notice about our privacy practices, our legal duties, and your rights concerning our health
information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes
effect 04/01/2003, and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are
permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our
Notice effective for all health information that we maintain, including health information we created or received before
we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make
the new Notice available upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional
copies of this Notice, please contact us.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:
Treatment: We may use or disclose your health information to a physician or other healthcare provider providing
treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations.
Healthcare operations include quality assessment and improvement activities, reviewing the competence or
qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training
programs, accreditation, certification, licensing or credentialing activities.
Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations,
you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you
give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures
permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or
disclose your health information for any reason except those described in this Notice.
To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section
of this Notice. We may disclose your health information to a family member, friend or other person to the extent
necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including
identifying or locating) a family member, your personal representative or another person responsible for your care, of
your location, your general condition, or death, if you are present, then prior to use or disclosure of your health
information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your
incapacity or emergency circumstances, we will disclose health information based on a determination using our
professional judgment disclosing only health information that is directly relevant to the person’s involvement in your
healthcare. We will also use our professional judgment and our experience with common practice to make reasonable
inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other
similar forms of health information.
Marketing Health-Related Services: We will not use your health information for marketing communications without
your written authorization.
Required by Law: We may use or disclose your health information when we are required to do so by law.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe
that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We
may disclose your health information to the extent necessary to avert a serious threat to your health or safety
or the health or safety of others.
National security: We may disclose to military authorities the health information of Armed Forces personnel
under certain circumstances. We may disclose to authorized, federal officials health information required for
lawful intelligence, counter-intelligence, and other national security activities. We may disclose to correctional
institutions or law enforcement officials having lawful custody of protected health information of inmate or
patient under certain circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders.
We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We
may also call or write to notify you of other treatments or services available at our office that might help you. Unless you
tell us otherwise, we will mail you an appointment reminder on a post card, and/or leave you a reminder message on
your home answering machine or with someone who answers your phone if you are not home.
PATIENT RIGHTS
Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request
that we provide copies in a format other than photocopies. We will use the format you request unless we cannot
practicably do so. (You must make a request in writing to obtain access to your health information.) You may obtain a
form to request access by contacting our office. We will charge you a reasonable cost-based fee for expenses such as
copies and staff time. You may also request access by sending us a letter. If you request copies, we will charge you $0.50
for each page, $25.00 per hour for staff time to locate and copy your health information, and postage if you want the
copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health
information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a
fee. Contact us for a full explanation of our fee structure.
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed
your health information for purposes, other than treatment, payment, healthcare operations and certain other activities,
for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period,
we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health
information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement
(except in an emergency).
Alternative Communication: You have the right to request that we communicate with you about your health
information by alternative means or to alternative locations. (You must make your request in writing.) Your request must
specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the
alternative means or location you request.
Amendment: You have the right to request that we amend your health information. (Your request must be in writing,
and it must explain why the information should be amended.) We may deny your request under certain circumstances.
Electronic Notice: If you receive this Notice on our Web Site or by electronic mail (e-mail), you are entitled to receive this
Notice in written form.
FOR MORE INFORMATION
If you want more information about our privacy practices, call or visit the office at the address or phone number shown
on this Notice.
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about
access to your health information or in response to a request you made to amend or restrict the use or disclosure of your
health information or to have us communicate with you by alternative means or at alternative locations, you may
complain to us using the contact information listed at the beginning of the Notice. You also may submit a written
complaint to the US Department of Health and Human Services. We will provide you with the address to file your
complaint with the US Department of Health and Human Services upon request.
We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a
complaint with us or with the US Department of Health and Human Services.
Monmouth Location
503-673-2503
380 Pacific Ave N Monmouth, OR 97361
Salem Location
503-363-2536
835 Commercial St SE Salem, OR 97306