Patient Privacy Policy

As a patient of our practice, your right to privacy and protection of personal health information will be upheld
with utmost importance. The following statement informs you of these rights in detail.

Notice of Privacy Practices for Protected Health Information

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!

With your consent, the practice is permitted by federal privacy laws to make uses and disclosures of your health
information for purposes of treatment, payment, and health care operations. Protected health information is the
information we create and obtain in providing our services to you. Such information may include documenting
your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment. It
also includes billing documents for those services.

Example of uses of your health information for treatment purposes:
A nurse obtains treatment information about you and records it in a health record. During the course of your
treatment, the doctor determines a need to consult with another specialist in the area. The doctor will share the
information with such specialist and obtain input.

Example of use of your health information for payment purposes:
We submit a request for payment to your health insurance company. The health insurance company requests
information from us regarding medical care given. We will provide information to them about you and the care
given.

Example of Use of Your Information for Health Care Operations:
We obtain services from our insurers or other business associates such as quality assessment, quality
improvement, outcome evaluation, protocol and clinical guidelines development, training programs,
credentialing, medical review, legal services, and insurance. We will share information about you with such
insurers or other business associates as necessary to obtain these services.

Your Health Information Rights

The health record we maintain and billing records are the physical property of the practice. The information in
it, however, belongs to you. You have a right to:

  • Request a restriction on certain uses and disclosures of your health information by delivering the request in
    writing to our office. We are not required to grant the request but we will comply with any request granted;
  • Request that you be allowed to inspect and copy your health record and billing recordyou may exercise
    this right by delivering the request in writing to our office;
  • Appeal a denial of access to your protected health information except in certain circumstances;
  • Request that your health care record be amended to correct incomplete or incorrect information by
    delivering a written request to our office;
  • File a statement of disagreement if your amendment is denied, and require that the request for amendment
    and any denial be attached in all future disclosures of your protected health information;
  • Obtain an accounting of disclosures of your health information as required to be maintained by law by
    delivering a written request to our office. An accounting will not include internal uses of information for
    treatment, payment, or operations, disclosures made to you or made at your request, or disclosures made to
    family members or friends in the course of providing care;
  • Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office; and,
  • Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office.

If you want to exercise any of the above rights, please contact Julie at 425-356-3000, in person or in writing,
during normal hours. She will provide you with assistance on the steps to take to exercise your rights.

Our Responsibilities

The practice is required to:

  • Maintain the privacy of your health information as required by law;
  • Provide you with a notice of our duties and privacy practices as to the information we collect and maintain
    about you;
  • Abide by the terms of this Notice;
  • Notify you if we cannot accommodate a requested restriction or request; and
  • Accommodate your reasonable requests regarding methods to communicate health information with you.

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and
to enact new provisions regarding the protected health information we maintain. If our information practices
change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and
requesting a copy of our “Notice” or by visiting our office and picking up a copy.

To Request Information or File a Complaint

If you have questions, would like additional information, or want to report a problem regarding the handling of
your information, you may contact Julie at 425-356-3000 or Julie@washingtonoralsurgery.com.

Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our
office by delivering the written complaint to our office. You may also file a complaint by mailing it or e-
mailing it to the Secretary of Health and Human Services of Washington.

  • We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and
    Human Services (HHS) as a condition of receiving treatment from the practice.
  • We cannot, and will not, retaliate against you for filing a complaint with the Secretary.

Other Disclosures and Uses

Notification
Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a
family member, personal representative, or other person responsible for your care, about your location, and
about your general condition, or your death.

Communication with Family
Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any
other person you identify, health information relevant to that person’s involvement in your care or in payment
for such care if you do not object or in an emergency.

Food and Drug Administration (FDA)
We may disclose to the FDA your protected health information relating to adverse events with respect to
products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or
replacements.

Workers Compensation
If you are seeking compensation through Workers Compensation, we may disclose your protected health
information to the extent necessary to comply with laws relating to Workers Compensation.

Public Health
As required by law, we may disclose your protected health information to public health or legal authorities
charged with preventing or controlling disease, injury, or disability.

Abuse & Neglect
We may disclose your protected health information to public authorities as allowed by law to report abuse or
neglect.

Correctional Institutions
If you are an inmate of a correctional institution, we may disclose to the institution, or its agents, your protected
health information necessary for your health and the health and safety of other individuals.

Law Enforcement
We may disclose your protected health information for law enforcement purposes as required by law, such as
when required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in the
custody of law enforcement.

Health Oversight
Federal law allows us to release your protected health information to appropriate health oversight agencies or
for health oversight activities.

Judicial/Administrative Proceedings
We may disclose your protected health information in the course of any judicial or administrative proceeding as
allowed or required by law, with your consent, or as directed by a proper court order.

Other Uses
Other uses and disclosures besides those identified in this Notice will be made only as otherwise
authorized by law or with your written authorization and you may revoke the authorization as
previously provided.

Website
If we maintain a website that provides information about our entity, this Notice will be on the website.

For a printable version of the privacy notice, please, Click Here.