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Privacy Notice

NOTICE OF USE OF PRIVATE HEALTH INFORMATION
Effective Date: April 14, 2003
Northwest Foot & Ankle

FOR YOUR PROTECTION 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.

Your Health Information is Private
We understand that information we collect about you and your health is personal. Keeping your health information private is one of our most important responsibilities. We are committed to protecting your health information and following all laws regarding the use of your health information. The law says:
1. We must keep your health care information from others who do not need to know it.
2. You may ask that we not share certain health care information. (In some instances, we may not be able to agree with your request.)

Who Sees and Shares my Health Information?
Your private health information may be used by health care providers such as doctors, nurses, therapist and social workers who take care of you. They may need your private health care information in order to determine your plan of care. This may cover health care services you had before now, or service you may have in the future.

We may share health information about you in order to help you get services you may need. We may also use your information to contact you about appointment reminders or tell you about your treatment

How is Payment Made?
Your health care provider send a bill (also called a "claim") to an insurance company or to a government program such as Medicare or Medicaid. The bill has all of the information about what services you had. We review the health care information and bills to make sure That you get quality care and that all laws providing and paying for your health care are being followed.

May I See My Health Information?
You may see your health information, unless it is the private notes taken by a mental health provider or it is apart of a legal case. Most of the time you can receive a copy if you ask. You may be charged a small fee for the copying costs.

If you think some of the information is wrong, you may ask in writing that it be changed or new information added. You may ask that the changes or new information be sent to others that have received your health information from us. You may ask for a list of any places where your health information may have been sent, unless it was sent for treatment, for payment, for checking to make sure you receive quality care, or to make sure the laws are being followed.

What if my Health Information needs to go somewhere else?
You may be asked to sign a separate form called and "authorization" form, allowing your health care information to go somewhere else if:

1. Your health care provider needs to send it to other places;
2. You want us to send it to another health care provider; or,
3. You want it sent to another person for you.

The authorization form tells us what, where and to whom the information must be sent. Your authorization is good for six (6) months or until the date you put on the form. You can cancel or limit the amount of information sent at any time by letting us know in writing.

NOTE: If you are less than 18 years of age, your parents or guardians will receive your private health care information, unless by law you are able to consent for your own health care treatment. If you are, then your private health information will not be shared with parents or guardians unless you sign an authorization form. You may ask to have your health information sent to a different person that is helping you with your health care.

Could My Health Information be Released Without My Authorization?
When private health information is release without authorization, it is normally used to support treatment or payment of medical situations or it may be released for the use of health care operations, which included any of the following activities:
( a ) quality assessment and improvement activities, including case management are care coordination.
( b ) competency assurance activities, including provider or health plan performance evaluation, credentialing and accreditation.
( c ) conducting or arranging for medical reviews, audits, or legal services. ( d ) business management and general administrative activities of the entity, including but not limited to: de-identifying protected health information or creating a limited data set.

May I Have a Copy of this Notice?
This notice is yours. If we change anything in this notice, you will get a new notice. You can obtain additional copies of this notice by calling our office at 503.243.2699. You can also view and print this notice by visiting our web site at: www.nwfootankle.com.

If you have medical insurance, you may receive other privacy notices. The policies and procedures contained in this notice are only for Northwest Foot & Ankle, but adhering to The Standards for Privacy of Individually Identifiable Health Information ("Privacy Rule") established by The U.S. Department of Health and Human Services to implement the requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

What if I have Questions or Complaints?
If you have questions about this notice, or you think we have not protected your private health information and you wish to file a complaint, please contact:

Office of Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509 F, HHH Building
Washington, D.C. 20201-0004
1-800-368-1019

Could My Quality of Care be Affected If I File a Complaint?
Absolutely not. It is against the law for us to take any retaliatory or other negative action if you file a complaint.

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