White Pine Physical Therapy, PLLC ◌ 4617 Chardonnay Ln NE, #101, Bainbridge Is, WA 98110 ◌ 206-552-8670
WA License: PT 61435548
HIPAA and Washington State Notice of Privacy Practices
Effective Date: July 6th, 2023
Contact Information
If you have any questions about this notice, please contact our designated Privacy Officer:
Annie Cumming
annie@whitepinept.com
206-552-8670
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 record contains personal information about you and your health. State and Federal law protects the confidentiality of this information. Protected Health Information (PHI) is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical and mental health, or condition, and related health care services. If you suspect a violation of these legal protections, you may file a report to the appropriate authorities in accordance with Federal and State regulations.
We reserve the right to change our practices and to make the new provisions effective for all your health information that we maintain.
Should our information practices change, a revised Notice of Privacy Practices will be available upon request. If there is a material change, a revised Notice of Privacy Practices will be distributed to the extent required by law. We will not use or disclose your health information without your authorization, except as described in our most current Notice of Privacy Practices.
We are required by law to provide you with this notice of our legal duties, your rights, and our privacy practices, with respect to using and disclosing your health information that is created or retained by White Pine Physical Therapy. Each time you visit us, we make a record of your visit. Typically, this record contains your symptoms, examination and test results, our assessment of your condition, a record of your treatment interventions, and a plan for future care or treatment. We have an ethical and legal obligation to protect the privacy of your health information, and we will only use or disclose this information in limited circumstances.
In general, we may use and disclose your health information for:
Treatment. We may use your protected PHI to provide you with treatment services.
Payment. We may use and disclose your protected PHI so that we can receive payment for the treatment services provided to you.
Healthcare Operations. We may use and disclose your PHI for certain purposes in connection with the operation of our professional practice, including oversight and consultation
Without your Authorization. State and Federal law also permits us to disclose information about you without your authorization in a limited number of situations, such as with a court order.
With your written authorization. We must obtain written authorization from you for other uses and disclosures of your PHI. You may revoke such authorizations in writing in accordance with 45 CFR. 164.508(b)(5).
Examples of how we may use or disclose your Protected Health Information:
Treatment. We can use your health information and share it with other professionals who are treating you. This may include coordination or management of your health care with a third party, consultation or coordination activities with other health care providers, or referral to another provider for health care services.
Healthcare Operations. We can use and share your health information to run our practice, improve your care, and contact you when necessary. This may include; disclosures to others for health care education, or to provide planning, quality assurance, peer review, or administrative, legal, financial, or actuarial services to assist in the delivery of healthcare. We may also contact you to remind you of your appointment.
Payment. We can use and share your health information to bill and get payment from health plans or other entities. This may include providing information to a third party payor, or, in the case of unpaid fees, submitting your name and amount owed to a collection agency.
Release to Family/Friends. Our staff, using their professional judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, your health information to the extent it is relevant to that person’s involvement in your care or for payment related to your care. We will provide you with an opportunity to object to such a disclosure whenever we practicably can do so. We may disclose the health information of minor children to their parents or guardians unless such disclosure is otherwise prohibited by law. However, please note that state law may prohibit us from disclosing medical information to a parent or guardian at the child’s request if the child is of a certain age.
Disaster Relief. We may disclose your health information in disaster relief situations where disaster relief organizations seek your health information to coordinate your care, or notify family and friends of your location and condition. We will provide you with an opportunity to agree or object to such a disclosure whenever we practicably can do so.
Marketing. In most circumstances, we are required by law to receive your written authorization before we use or disclose your health information for marketing purposes. However, we may market services or products to you in face-to-face communications. Under no circumstances will we sell or market our patient lists or your health information to a third party without your written authorization.
Fundraising. We may contact you for fundraising efforts, but you can tell us not to contact you again.
Incidental Use and Disclosure. We are not required to eliminate every risk of incidental use or disclosure of your PHI. Specifically, a use or disclosure of your PHI that occurs as a result of, or incident to an otherwise permitted use or disclosure is permitted as long as we have adopted reasonable safeguards to protect your PHI, and the information being shared was limited to the minimum necessary.
Authorization for Other Uses of Medical Information
Uses of medical information not covered by our most current Notice of Privacy Practices or the laws that apply to us will be made only with your written authorization. You should be aware that we are not responsible for any further disclosures made by the party you authorize us to release information to. If you provide us with authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. Such revocation of authorization will not be effective for actions we may have taken in reliance on your authorization of the use or disclosure.
Other Uses and Disclosures That Do Not Require Your Authorization
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Public Health and Safety Activities. We may disclose your PHI for public health activities. These activities generally include the following:
health oversight agencies for activities authorized by law, such as audits, investigations, and inspections;
prevention or control of disease, injury, or disability;
notifications to people who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
organ or tissue donation;
reporting suspected abuse, neglect, or domestic violence. We will make this disclosure when required by law, and include only the information necessary for a mandated report;
reporting your PHI to law enforcement if we reasonably believe disclosure will avoid or reduce a threat to the health and safety of yourself or any third party.
Research. We may disclose PHI to researchers if (a) an Institutional Review Board reviews and approves the research and a waiver to the authorization requirement; (b) the researchers establish protocols to ensure the privacy of your PHI; and (c) the researchers agree to maintain the security of your PHI in accordance with applicable laws and regulations.
Comply with the law. We may share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Deceased Clients. We may share PHI with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests. We may use or share PHI for workers’ compensation claims, law enforcement purposes, or with a law enforcement official, or for special government functions such as military, national security, and presidential protective services.
Respond to lawsuits and legal actions. We may share PHI in response to a court or administrative order, or in response to a subpoena.
Specially protected information
Some types of information have greater protection under Washington State or federal laws. The above disclosure practices don't necessarily apply to these types of information, which include confidential HIV-related information that is protected by Washington State laws; alcohol and substance abuse treatment information that is protected under both Washington State and federal laws; and mental health treatment information that is protected.
Your Rights
When it comes to your health information, you have certain rights. You have the following rights regarding PHI that we maintain about you. Any requests with respect to these rights must be in writing. A brief description of how you may exercise these rights is included.
Right to Inspect and Copy. You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you.To inspect and copy medical information, you must submit a written request to our privacy officer. If you request a copy of your medical information, we may charge a reasonable fee for the costs associated with your request.
You also have the right to request that an electronic copy of your record be sent to another individual or entity. We may charge you a reasonable cost based fee limited to the labor costs associated with transmitting the electronic health record.
Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. To request an amendment, your request must be made in writing and submitted to our privacy officer. In addition, you must provide a reason that supports your request. In certain cases, we may deny your request.
If we deny your request for amendment, you may submit a statement of disagreement. We may reasonably limit the length of this statement. Your letter of disagreement will be included in your medical record, but we may also include a rebuttal statement.
Right to Request Confidential Communications. You can ask us to contact you in a specific way (for example, home or office phone) or at a specific location. To request confidential communications, you must make your request in writing to your provider or our privacy officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to Request Restrictions. You can ask us not to use or share certain health information for treatment, payment, health care operations or to family members involved in your care. We are not required to agree to your request, and we may say “no” if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
To request restrictions, you must make your request in writing to our privacy officer. In your request, you must tell us:
what information you want to limit;
whether you want to limit our use, disclosure, or both; and
to whom you want the limits to apply
Right to an Accounting of Disclosures. You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. Under limited circumstances mandated by federal and state law, we may temporarily deny your request for an accounting of disclosures.
Right to a Copy of this Notice. You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Right to Opt Out. You have the legal right to choose not to receive marketing and fundraising communications from us.
Right to Notice of Breach. You have the right to be notified of any breach of your unsecured private health information.
Right to a Personal Representative. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.
Right to File a Complaint. If you believe we have violated your privacy rights, you may file a complaint in writing with us through our Privacy Officer. You also have the right to file a complaint to the Washington Department of Health or to the US Secretary of Health and Human Services by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you in any way for filing a complaint.
Our Responsibilities
We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time.