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.
UNDERSTANDING YOUR HEALTH RECORD
A record is made each time you are treated at our Clinic. Your injuries, evaluation and test results, diagnosis, treatment, and
a plan of care are recorded. This information is most often referred to as your “health or medical record,” and it serves as a
basis for planning your care and treatment. It also serves as a means of communication among any and all other health
professionals who may contribute to your care. Understanding what information is retained in your record and how that
information may be used and shared will help you to ensure its accuracy and enable you to understand who, what, when,
where, and why others may be allowed access to your health information. This Clinic uses health information about you as
described in this Notice. Your health information is contained in a medical record that is the physical property of our Clinic.
OUR RESPONSIBILITIES
This Clinic is required by law to maintain the privacy of your health information and to provide you with notice of our legal
commitment and privacy practices with respect to the information we collect and maintain about you. This Clinic is required
to abide by the terms of this notice, as currently in effect, and to notify you if we are unable to grant your requested
restrictions or reasonable desires to communicate your health information by alternative means or to alternative locations.
REVISIONS
This Clinic reserves the right to change its practices and this Notice and effect the new provisions with respect to all health
information that it maintains (including information that this Clinic had prior to implementation of the new provision). If
we update this Notice, we will provide the revised Notice to you at your next appointment and post a copy of it on our
website: ptnorthwest.com. Other than for reasons described in this notice, this Clinic agrees not to use or disclose your
health information without your authorization.
USE OR DISCLOSURE OF YOUR HEALTH INFORMATION WITHOUT YOUR AUTHORIZATION
This Clinic may use and disclose your health information without your authorization in order to provide “Treatment,” obtain
“Payment,” and perform our “Health Care Operations,” as well as other specific reasons as detailed below:
• Treatment – We may use and disclose health information about you to provide you with products and services or
related medical treatment or services. To this end, we may communicate with other health care providers regarding your
treatment and coordinate and manage your health care with others. For example, information related to your treatment may
be shared with a health care provider, such as your physician, a pharmacist, nurse, or other person providing health services
to you. This information is necessary for health care providers to determine what treatment you should receive. Health care
providers also may record actions taken by them in the course of your treatment and note how you responded to the actions.
We may also use your medical information to give you information about treatment options or other health-related benefits
and services that may interest you.
• Payment – We may use and disclose health information about you to others for purposes of receiving payment for
treatment and services that you receive. For example, information regarding treatment you have received may be sent to
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you or someone who pays on your behalf (such as a family member or an insurance company) in order for this Clinic to
receive payment. The information used in this fashion may include details regarding your services that identify you and
could identify your diagnosis or treatment. Although it is unlikely, if other treatment providers need medical information
about your treatment in order to bill for their services, we may provide it to them. We will comply with your request not to
disclose your medical information to your insurance company if the information relates solely to a healthcare item or service
for which you have paid out of pocket and in full to us.
• Health Care Operations – We may use and disclose health information about you for administrative and
operational purposes. Risk management or quality improvement personnel may use health information about you to assess
the care and outcomes in your case and others like it. The results will be used internally to continually improve the quality
of care for all patients. For example, we may combine medical information about many patients to evaluate the need for
new products, services, or treatments. We may disclose information to health care professionals, students, and other
personnel for review and training purposes. We also may combine health information we have with other sources to see
where we can make improvements. We may remove information that identifies you from this set of health information to
protect your privacy and to allow others to use the information to study health care without learning the identity of the
specific patients. We may also use and disclose your medical information to:
• evaluate the performance of our staff and your satisfaction with our services;
• learn how to improve our facilities and services;
• determine how to continually improve the quality and effectiveness of the health care we provide; and
• conduct training programs or review competence of health care professionals.
• Individuals Involved in Your Care or Payment for Your Care – We may release health information about you
to a family member, guardian, or friend who is involved in your medical care. We also may give information about you to
someone who helps pay for your care. If you have any objection to sharing your medical information in this way, please
contact the Privacy Officer, whose contact information is listed at the end of this Notice.
• You or Your Personal Representative – We may disclose your medical information to you or to a representative
appointed by you or designated by applicable law.
• Disaster Relief – In addition, we may disclose health information about you to an entity assisting in a disaster relief
effort (such as the Red Cross) so that your family can be notified about your condition, status, and location. We may also
disclose medical information about you to local authorities or utility companies if your home care is considered “lifesupporting” and you require immediate attention in the event of an emergency or power outage.
• Business Associates – We may share your medical information with outside companies that perform services for
us, such as companies that receive phone calls from patients when our offices are closed and companies that store patient
files for us. In addition, we also contract with accountants, consultants, and attorneys to provide us with services. These
outside vendors are called “Business Associates” and they are required to safeguard your information by HIPAA and by
contract.
• Participation in Health Information Exchanges – We may participate in one or more health information
exchanges (HIEs) and may electronically share your medical information for treatment, payment, and permitted health care
operations purposes with other participants in the HIE. Depending on state law requirements, you may be asked to “opt-in”
in order to share your information with HIEs, or you may be provided the opportunity to “opt-out” of HIE participation.
HIEs allow your health care providers to efficiently access your medical information that is necessary for treating you and
other lawful purposes.
• Reminders – We may use health information about you to provide you with reminders about appointments.
• Alternative Treatments and Health Benefits – We may use health information about you to provide you with
information about alternative treatments or other health-related benefits and services that may be of interest to you.
• Future Communications – We may communicate with you via newsletters, mailings, or other means regarding
treatment options, health-related information, disease management programs, wellness programs, or other community-based
initiatives or activities in which we are participating.
• Required by Law – We may use and disclose health information about you as required by federal, state, or local
law.
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• Public Health – We may use or disclose health information about you for public health activities, such as assisting
public health authorities or other legal authorities to prevent or control disease, injury, or disability; reporting deaths; and
reporting reactions to medications or problems with products.
• Food and Drug Administration (FDA) – We may use or disclose health information for purposes of notifying the
FDA of adverse events with respect to medication and product defects or post marketing surveillance information to enable
product recalls, repairs, or replacements.
• Health and Safety – We may use or disclose health information about you to avert a serious threat to the health or
safety of you, the public, or any other person pursuant to applicable law.
• Protective Services for the President and Others – Your medical information may be disclosed to authorized
federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or to
conduct special investigations.
• National Security and Intelligence Activities – We may disclose your medical information to authorized federal
officials for national security and intelligence activities authorized by law.
• Military and Veterans – If you are a member of the armed forces, your medical information may be released as
required by military command authorities.
• Medical Examiners and Others – We may use or disclose health information about you to medical examiners,
coroners, or funeral directors to allow them to perform their lawful duties.
• Organ and Tissue Donation – If you are an organ or tissue donor, we may use or disclose health information about
you to organizations that help with organ, eye, and tissue donation and transplantation, or to an organ donation bank.
• Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we
may release medical information about you to the correctional institution or law enforcement official.
• Workers Compensation – We may use or disclose health information about you to comply with laws and
regulations related to workers compensation.
• Research – We may use or disclose health information about you for research purposes under certain circumstances.
For example, we may disclose health information about you to a research organization if an institutional review board or
privacy board has reviewed and approved the research proposal after establishing protocols to ensure the privacy of your
health information. All research projects involving your medical information must be approved through a special review
process to protect your confidentiality.
• Information Not Personally Identifiable – We may use or disclose health information that does not personally
identify you or reveal who you are.
• Law Enforcement – We may disclose your health information to the police or other law enforcement officials as
required or permitted under state law.
• Health Oversight Activities – We may disclose your health information to a health oversight agency that oversees
the health care system and is charged with responsibility for ensuring compliance with rules of governmental health
programs, such as Medicare or Medicaid. These oversight activities include, for example, audits, investigations, inspections,
and licensure.
• Victims of Abuse, Neglect or Domestic Violence – If this Clinic reasonably believes you are a victim of abuse,
neglect or domestic violence, we may disclose your health information to the appropriate governmental agency authorized
by law to receive reports of such abuse, neglect or domestic violence.
• Judicial and Administrative Proceedings – This Clinic may disclose your health information in the course of a
judicial proceeding in response to a legal order, subpoena, discovery request, or other lawful process.
USE OR DISCLOSURE OF YOUR HEALTH INFORMATION WITH YOUR AUTHORIZATION
Other uses and disclosures not described in this Notice will be made only with the individual’s written authorization. You
may revoke (take back) an authorization that you had previously provided by giving us written notice. In that case, we will
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cease using or disclosing your information for the purpose that you had authorized. However, we are unable to retract or
invalidate any uses or disclosures that were made with your permission before you revoked your authorization. The
following are some examples of uses or disclosures that require your authorization:
• Psychotherapy Notes – We do not typically maintain psychotherapy notes on any of our patients. However, if we
wanted to use or disclose any psychotherapy notes we had in our possession (for instance, as part of your medical record),
we would have to ask for you authorization to do so, unless the use or disclosure was to undertake certain treatment,
payment, or health care operation activities as described above.
• Other Sensitive Information – In addition, other types of information may have greater protection under federal
or state law, such as certain drug and alcohol information, HIV/AIDS and other communicable disease information, genetic
information, mental health information, or information about developmental disabilities. We do not generally maintain this
type of information. But, if we do, we may be required to get your written permission before disclosing it to others, and we
may seek that permission if permitted by law.
• Marketing – We must obtain your authorization before we use or disclose your health information for marketing
purposes, unless that marketing relates to certain treatments you are already undergoing (or available alternatives), the
marketing is conducted face-to-face, or the marketing involves a promotional gift of nominal value. If we receive any
payment for the use of your information for marketing purposes, we will tell you so in the authorization that we ask you to
sign.
• Sale of Health Information – This Clinic will not sell your health information. However, if we change this policy
in the future, we will be required to seek your authorization before selling any of your health information.
YOUR HEALTH INFORMATION RIGHTS
You have the following rights with respect to health information about you. To exercise any of your rights, please see the
contact information at the end of this notice.
• Right to Inspect and Copy – You have the right to inspect and/or obtain a copy of the health information about
you that we maintain in certain groups of records that are used to make decisions about your care. You have the right to an
electronic copy of your health information if it is maintained electronically. Your request must be in writing. If you request
a copy of your health information, we may charge you a fee to cover the costs of copying and mailing the information. If
you request a copy of your information electronically on a portable electronic media device (such as a CD or USB drive),
we may charge you for the cost of that media device. In certain very limited circumstances, we may deny your request to
inspect and copy your health information. If you are denied access to your health information, we will explain our reasons
in writing. You have the right to request that the decision be reviewed by another person. We will comply with the outcome
of the review.
• Right to Amend – If you feel that health information about you that we maintain in certain groups of records is
inaccurate or incomplete, you have the right to request that we amend the information. You have the right to request an
amendment as long as we maintain the information. Your request must be in writing and include a reason supporting the
request. In certain circumstances, we may deny your request to amend your health information. If your request for an
amendment is denied, we will explain our reasons in writing. You have the right to submit a statement explaining why you
disagree with our decision to deny your amendment request. We will share your statement when we disclose health
information about you that we maintain in certain groups of records.
• Right to an Accounting of Disclosures – You have the right to request an accounting or detailed listing of certain
disclosures of your health information. The accounting will not include all disclosures of your medical information. For
example, you do not have the right to request an accounting of disclosures of your medical information made (1) for purposes
of treatment, payment, and health care operations; (2) to you and pursuant to your authorization; or (3) for other purposes
for which federal law does not require us to provide an accounting. The time period covered by the accounting is also limited
to six years. Your request must be in writing. If you request an accounting more often than once every twelve (12) months,
we may charge you a fee to cover the costs of preparing the accounting.
• General Right to Request Restriction – You have the right to request a restriction or limitation on the health
information about you that we use or disclose. Your request must be in writing. Please be aware that we are not required to
agree to your request for restrictions. In your request, you must tell us: (1) what information you want to limit; (2) whether
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you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply (for example, disclosures to
your spouse). If we agree to your request for a restriction, we will comply with it unless the information is needed for
emergency treatment.
• Right to Restrict Disclosure to a Health Plan – You have the right to request that we not disclose the portion of
your health information developed during a treatment that you (or someone else) paid for entirely out-of-pocket to your
health plan. This request must be in writing. We may not refuse this request.
• Right to Request Alternative Communications – You have the right to request that we communicate with you
about medical matters in a certain way or at a certain location. To request confidential communications, you must make
your request in writing. Your request must specify how or where you wish to be contacted. We will not ask you the reason
for your request. We will agree to the request to the extent that it is reasonable for us to do so. For example, you may request
that we use an alternative address for delivery or communication purposes.
• Right to Revoke Authorization – There are occasions when you may give us written authorization to use or
disclose your health information. You have the right to revoke your authorization to use or disclose health information,
except to the extent that action has been taken in reliance upon your authorization.
• Right to be Notified of a Breach – In the event some portion of your health information is lost, stolen, or otherwise
improperly accessed, you have the right to be informed to the extent required under applicable law. You will be informed
in writing, unless you have previously established a preference for electronic communications.
• Right to Copy of Notice of Privacy Practices – You have the right to a paper copy of our Notice of Privacy
Practices at any time. To obtain a copy of our current Notice of Privacy Practices, please contact our Privacy Officer at the
address and telephone number provided at the end of this notice. You may also obtain a copy of this notice from our website:
ptnorthwest.com. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this
Notice.
QUESTIONS AND COMPLAINTS
For additional information about this Notice or if you have a question, you may contact our Privacy Officer at (713) 344-
0351. If you believe your privacy rights have been violated, you have the right to complain to this Clinic and to the Secretary
of the U. S. Department of Health and Human Services. To submit a complaint to the Department of Health and Human
Services, you may contact the Office for Civil Rights of the Department of Health and Human Services, Hubert H.
Humphrey Building, 200 Independence Avenue, SW, Room 509F, Washington, D.C. 20201. Some states may allow you to
file a complaint with state’s Attorney General, Office of Consumer Affairs, or other state agency as specified by applicable
state law. You may make a complaint with this Clinic via the contact information at the end of this notice. You will not be
retaliated against for filing a complaint.
CONTACT INFORMATION
If you have any questions, wish to obtain copies of your health information, amend, request an accounting, or exercise any
other rights identified in this notice, or would like to file or discuss a complaint regarding our privacy practices, please
contact this identified in this notice, or would like to file or discuss a complaint regarding our privacy practices, please
contact this Clinic’s Privacy Officer by telephone at (713) 344-0351, by fax at (713) 430-4044, or by email at
Compliance@usph.com.
Notice of Privacy Practices Availability: This notice will be posted where registration occurs. All individuals receiving
care will be provided with a hard copy upon request and asked to acknowledge receipt