Orthopedics Northwest, PLLC

Privacy Practice

NOTICE OF PRIVACY PRACTICES

This Notice is effective April 14, 2003

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.

NOTICE

We keep a record of the health care services we provide you. You may ask us to see and copy that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may also ask us to correct that record or get more information about it at the address for our Privacy Official provided elsewhere in this Notice.

If you have any questions about this Notice please contact our Privacy Official at (509) 834-6279.

A. Our Duties Regarding Your Medical Information

We are required by law to maintain the privacy of your medical information. Your medical information is information that may identify you and that relates to: your past, present, or future physical or mental health or condition, to the provision of health care to you, or to the payment history for your health care.

We are required to provide to you a notice of our legal duties and privacy practices as they relate to your medical information.

We are required to abide by the terms of the notice of privacy practices currently in effect.

We reserve the right to change the terms of this notice at any time. We also reserve the right to make the provisions of the new notice effective for all medical information we maintain, including any medical information created or received by us before the change. Whenever we revise this notice, we will post the revised notice at the following location: 111 South 11th Ave Suite 320, Yakima, WA 98902. We will also make the revised notice available at the above location for you to take with you. Please check with us periodically to see if we have made any revisions, as we may not otherwise notify you of a revision to this notice.

B. Uses and Disclosures of Your Medical Information

We use your medical information and, under certain circumstances, disclose your medical information for a number of different purposes. Some of our uses and disclosures require your authorization and some do not.

1. Uses and Disclosures We May Make Without Your Authorization

The following are examples of the types of uses and disclosures of your medical information that we are permitted or required to make without your authorization:

For Treatment: We may use or disclose your medical information to provide health care and related services to you. This includes uses made by us or disclosures made to other health care providers or third parties to coordinate or manage the provision of health care and related services to you. For example, information obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the best course of treatment. Members of your health care team will then use that information to provide treatment, and they will record their observations and the actions they took. We may also disclose your medical information to another health care provider who has provided or is providing health care services to you. For example, if we seek specialized treatment for a patient, when necessary treatment is outside our current specialty training, we may disclose your medical information in a referral letter to the specialist. As another example, we may disclose some of your medical information to another health care provider to coordinate appropriate physical or occupational therapy treatments.

For Payment: We may use your medical information without your authorization to obtain payment for your health care services. For example, we may use your medical information in preparing and sending a bill to you. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used. However, unless you have given us a written authorization, we will not disclose your medical information to your health plan or some other third-party payer.

We are allowed by law, and we may, disclose your medical information to another health care provider for the payment activities of that other health care provider. However, we will disclose only the limited medical information needed by that health care provider for that purpose. For example, if another health care provider has assisted us in providing you treatment, we may disclose demographic, billing, and diagnosis information to that other provider for billing purposes.

For Health Care Operations: We may use and disclose your medical information in performing a variety of business activities called health care operations. These are activities necessary to run our practice and make sure that all of our patients receive quality care. For example, we may use your medical information to review our treatment services and to evaluate the performance of our staff in caring for you. We may also disclose information to licensed health care providers (including physicians and nurses), technicians, medical students, and our staff for review and learning purposes. We may also disclose your medical information to other entities for their health care operations if the entity has a relationship with you and the information pertains to that relationship.

Appointment Reminders: We may use and disclose your medical information to contact you as a reminder that you have an appointment.

Treatment Alternatives: We may use and disclose your medical information to inform you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-related Benefits and Services: We may use or disclose your medical information to inform you about health-related benefits or services you may be interested in.

Newsletters and Other Materials: We may use your medical information to send to you newsletters or other materials informing you of the services we provide, or providing to you general health or wellness information.

Individuals Involved In Your Care: We may disclose medical information to your immediate family members or a person with whom you are known to have a close personal friendship who are involved in your health care. We will disclose only the medical information directly relevant to such persons involvement. We may also use or disclose your medical information to notify, or assist in the notification of a family member, your personal representative, or another person responsible for your care of your location, general condition, or death. We will not use or disclose your medical information in these circumstances until one of the following occurs: (i) we have obtained your agreement; (ii) we have provided you with an opportunity to object to the disclosure, and you do not express an objection; (iii) we reasonably infer from the circumstances, based on the exercise of professional judgment, that you do not object to the disclosure; or (iv) if you are not present, or you cannot be provided the opportunity to agree or object because of your incapacity or an emergency circumstance, we determine, in the exercise of professional judgment, that a disclosure is in your best interests. For instance, if we telephone you and you are not available, we may leave a message with someone in your home.

Parents and Guardians: If you are an unemancipated minor, we may disclose your medical information to your parents, guardian, or someone acting in the capacity of your parent. Except, we will not disclose your medical information regarding health care services: (i) that you consent to receive, where no other consent to such health care service is required by law; (ii) that you may lawfully obtain without the consent of a parent or guardian, and you, a court, or another person authorized by law consents to such health care service; or (iii) one of your parents or your guardian agrees that we may keep such information confidential.

Powers of Attorney and Guardians: If you are an adult or an emancipated minor, we may disclose your medical information to a person who has authority to act on your behalf in making decisions related to health care. However, we will disclose only your medical information applicable to that persons authority.

Personal Representatives: If you become deceased, we may disclose your medical information to the personal representative for your estate, or, if there is no personal representative, to certain persons who are authorized by law to exercise rights on your behalf. We will only disclose your medical information applicable to that persons authority.

Business Associates: We may have contractual relationships with people or companies that perform certain services on our behalf (such as transcription or collection agencies). We call these people or companies business associates. When permitted by law, we may disclose your medical information to our business associates, or allow them to create or receive medical information on our behalf. To protect the privacy of your medical information, we have contracts with our business associates requiring them to safeguard your information.

Form of Certain Communications: We may leave messages on your answering machine or send appointment reminders to you on postcards unless you request us in writing not to do so.

For Fundraising: Although we are allowed to disclose certain of your information for fundraising purposes, we do not do so.

For Directory Purposes: Although we are allowed to keep certain limited information about you in a directory to give to anyone who asks for you by name, we do not do so.

2. Other Uses and Disclosures We May Make Without Your Authorization

When Required By Law: Under some circumstances, we are required by law to use or disclose your medical information. For example, state law requires us to report known or suspected cases of child abuse or neglect or abuse or neglect of a vulnerable adult. In addition, we may be required to use or disclose medical information as a result of a court-ordered warrant or a subpoena issued by a court. We may also be required to disclose medical information to government agencies to determine our compliance with federal regulations. When we are required by law to use or disclose your medical information, our uses and disclosures will comply with and be limited to the requirements of the law.

For Public Health Activities: Under some circumstances, we are required to use or disclose medical information for public health activities. These activities include, but are not limited to, preventing or controlling disease, injury, or disability; performing public health investigations or health interventions; and responding to child abuse or neglect. They may also include disclosures of certain medical information to employers about light duty work for an employee, or if the medical information is about a workplace injury or illness, a workplace medical surveillance, or a return-to-work examination.

For Health Oversight Activities: We may use or disclose your medical information when such use or disclosure is required to determine our compliance with state or federal licensure, certification, or registration rules.

For Judicial and Administrative Proceedings: We may use or disclose your medical information when such use or disclosure is required by an appropriate discovery request or compulsory process of a judicial or administrative proceeding that complies with the relevant law.

For Law Enforcement Purposes: We may disclose your medical information to a law enforcement authority for law enforcement purposes, to the extent we are required or permitted to do so by law. We may also disclose certain limited medical information in response to a law enforcement officials request, where the purpose of the request is to identify or locate a suspect, fugitive, material witness, or missing person.

Regarding Decedents: We may disclose medical information regarding a decedent to county coroners and medical examiners for the investigation of deaths.

For Research: We may disclose certain medical information under certain circumstances for research purposes.

To Prevent a Serious Threat to Health or Safety: We may use or disclose your medical information if we believe that the use or disclosure will avoid or minimize an imminent danger to the health or safety of any person or to the public. Any disclosure, however, would only be to someone able to help prevent or minimize the danger. Our uses and disclosures for this purpose will be consistent with applicable law and the standards of ethical conduct for the use or disclosure of medical information.

To Correctional Institutions: We may disclose a patients medical information to an official of a penal or other custodial institution in which the patient is detained, but such disclosure will be only for the purposes permitted by law.

For Workers Compensation: We may disclose your medical information as authorized and to the extent necessary to comply with state workers compensation laws.

3. Uses and Disclosures That Require Your Authorization

All other uses and disclosures of your medical information will be made only with your written authorization. This includes, without limitation, the following:

For Payment: With your written authorization, we may disclose your medical information to obtain payment for your health care services. If you authorize us to disclose your medical information for this purpose, we may disclose portions of your medical information to insurance companies, health plans and their agents, other third-party payers, billing companies, collection agencies, and consumer reporting agencies. For example, we may send a bill to your health plan or some other third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

Ability to Revoke Authorizations: At any time, you may revoke an authorization for us to use or disclose your medical information; provided you do so in writing. However, a revocation of an authorization is not effective: (i) as to disclosures we are required to make to obtain payment for health care services we have provided; (ii) where we have taken substantial action in reliance on the authorization; or (iii) if the authorization was obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest either a claim under the policy or the policy itself.

For Organ Donation: We may use or disclose medical information to organ procurement or similar organizations to facilitate organ or tissue donation and transplantation.

Military Personnel: We may use and disclose medical information of members of national or foreign armed forces as required by command authorities.

Specialized Government Purposes: We may disclose medical information to federal officials as authorized by law to permit them to conduct national security activities or provide protective services to the President and others.

C. Special Protections for information related to Certain Medical Information

Special privacy protections apply to information related to mental health, alcohol and other substance abuse, and HIV/AIDS. The practices described in Section B may not apply to this type of medical information. We will disclose such information only when allowed by law.

D. Your Rights Regarding Your Medical Information

You have several rights regarding your medical information that are explained below:

Right to Request Restrictions: You have the right to request us to restrict our uses or disclosures of your medical information. We are not required to agree to your requested restriction, except in the following circumstances: (i) you have directed us in writing not to make disclosures of your medical information to another health care provider that has previously provided health care to you, where we are disclosing the information for the purpose of providing health care to you; or (ii) you have instructed us in writing not to make disclosures that we would otherwise make to your family members or friends. Even if we agree to your request, we may not follow your restrictions if the restricted medical information is needed to provide to you emergency treatment. Only our licensed health care professionals may agree to your request. All such requests must be made to one of our licensed health care professionals.

Right to Receive Confidential Communications: You have the right to request that we communicate with you by specific means or at specific locations of your choosing. For example, you may request that we contact you only at your work address, or by e-mail. We will accommodate your reasonable requests. Your request must be in writing, and delivered to our Privacy Official at the address given at the end of this notice. Your request must specify the alternative address or other method of contact. If the request will affect payment for health care (for example, who is notified in the billing process), you must also provide written information as to how payment, if any, will be handled. This right applies only to communications from us to you, or to communications from us that would otherwise be sent to the named insured of an insurance policy that covers you as a dependent of the named insured.

Right to Inspect and Copy Your Medical Information: Generally, you have the right to inspect and obtain copies of your medical information in our medical records. We may charge you a fee for any copies, as provided by law. Under some circumstances, we may deny your request. If we deny your request, we will tell you in writing the reasons for our denial. We will also describe your rights, if any, to have our decision reviewed. All requests for access to inspect or to obtain copies of your medical information must be in writing, signed by you, and must be delivered to our Privacy Official at the address given at the end of this notice.

Right to Amend Your Medical Information: You have the right to request us to make changes to your medical information. Under some circumstances, we may deny your request. If we deny your request, we will tell you in writing the reasons for our denial. We will also describe your right to give us a written statement disagreeing with our denial. If you give us such a statement, we will append or otherwise link the statement to your medical information. We have the right to prepare a written rebuttal statement to your statement, for inclusion in your medical information. If we prepare such a statement, we will provide a copy to you. All requests to amend your medical information must be in writing, signed by you, and must be delivered to our Privacy Official at the address given at the end of this notice.

Right to Receive an Accounting of Disclosures: You have the right to receive a list of the disclosures we have made of your medical information. However, this right is subject to certain exemptions, restrictions, and limitations. For example, this right does not extend to certain disclosures, including, but not limited to, disclosures made in connection with: (i) your treatment; (ii) obtaining payment for our health care services; (iii) our health care operations; and disclosures that occurred prior to April 14, 2003; and (iv) disclosures you have authorized. You have a right to one list in every 12-month period for fee. We may charge you for the cost of providing any additional lists in that same 12-month period. We will notify you of any cost involved so that you may choose to withdraw or modify your request before any costs are incurred.

Right to Receive a Paper Copy of this Notice: You have the right to receive a paper copy of this notice, upon request, even if you have agreed to receive an electronic copy of this notice.

E. Complaints

If you believe that we have violated your privacy rights you may complain to us or to the Secretary of the federal Department of Health and Human Services. If you complain to us, your complaint must be in writing, it must describe the acts or omissions you believe to be in violation of your rights, and it must be delivered to our Privacy Official at the address given at the end of this notice.

You will not be retaliated against for filing a complaint.

F. Contact

You may contact our Privacy Official at the following location:

Privacy Official

Orthopedics Northwest, P.L.L.C.

111 South 11th Ave Suite 320

Yakima, WA 98902

(509) 834-6279