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.

Emerald City Naturopathic Clinic respects your privacy. We understand that your personal health information is very sensitive. We will not disclose your information to others unless you tell us to do so, or unless the law authorizes or compels us to do so.

The law protects the privacy of the health information we create and obtain in providing our care and services to you. For example, your protected health information includes your symptoms, test results, diagnoses, treatment, health information from other providers, and billing and payment information relating to these services. Federal and state law allows us to use and disclose your protected health information for purposes of treatment and health care operations. State law requires us to get your authorization to disclose this information for payment purposes.

Examples of Use and Disclosures of Protected Health Information for Treatment, Payment, and Health Operations

For treatment:

• Information obtained by a nurse, physician, or other member of our health care team will be recorded in your medical record and used to help decide what care may be right for you.
• We may also provide information to others providing you care. This will help them stay informed about your care.

For payment:

• We request payment from your health insurance plan when we are contracted providers. Health plans need information from us about your medical care. Information provided to health plans may include your diagnoses, procedures performed, or recommended care.
• We bill you for amounts due which have not been paid at the time of service. We may send your account to a collection agency and take other measures permitted by law to collect money you owe us that we have been unable to collect from you by our normal billing processes.

For health care operations:

• We use your medical records to assess quality and improve services.
• We may use and disclose medical records to review the qualifications and performance of our health care providers and to train our staff.
• We may contact you to remind you about appointments and give you information about treatment alternatives or other health-related benefits and services.
• We may contact you to inform you of fund-raisers or other services of the Clinic.
• We may use and disclose your information to conduct or arrange for services, including:
  • medical quality review by your health insurance plan;
  • accounting, legal, risk management, and insurance services;
  • audit functions, including fraud and abuse detection and compliance programs.

Your Health Information Rights

The health and billing records we create and store are the property of Emerald City Naturopathic Clinic, Inc. P.S. The protected health information in it, however, generally belongs to you.

• You may request and receive from us a paper copy of our most current Notice of Privacy Practices for Protected Health Information ("Notice"), and ask questions about this Notice.
• You may ask us to restrict certain uses and disclosures of your protected health information. You must deliver this request in writing to us. We are not required to agree to those restrictions, but will review your request and inform you of any action taken. We cannot agree to restrictions on uses or disclosures that are legally required, or which are necessary to administer our business.
• In most cases you may inspect and obtain a copy of your protected health information. You must make this request to the Office Manager in writing. We have a form available for this type of request. We may charge you a fee for the costs of copying, mailing, and supplies that are necessary to fulfill your request. We may deny your request to inspect and copy in certain limited circumstances.
• In case of a denial to allow you access to your records, you may have another health care provider of the same specialty review your records and our denial of access to them- except in certain circumstances.
• You may ask us to change our record of your health information. You must give us this request in writing, and include a reason that supports your request. In certain cases, we may deny your request for amendment. If your request is denied, you may write a statement of disagreement. It will be stored in your medical record, and included with any release of your records.
• You may request and receive an accounting of disclosures of your protected health information that we have made since April 14, 2003, for most purposes other than treatment, payment, or health care operations. This accounting will not include disclosures to third party payors. You must make your request in writing to our Office Manager, and may receive this information without charge once every 12 months. We will notify you of the cost involved if you request this information more than once in 12 months. Your request must specify the time period. The time period may not be longer than 1 year and may not include dates before April 14, 2003.
• You may ask that your health information be given to you by another means or at another location. For instance, you may request that we contact you at a different residence or PO Box. To request confidential communication of your PHI, you must submit a signed and dated written request to our Office Manager, telling us how or where you would like to be contacted. We will accommodate all reasonable requests.
• You may cancel prior authorizations to use or disclose health information by giving us a written revocation. Your revocation does not affect information that has already been released. It also does not affect any action taken before we have received your revocation. Sometimes you cannot cancel an authorization if its purpose was to obtain insurance.

Our Responsibilities

We are required to:

• Keep your protected health information private.
• Give you this Notice.
• Follow the terms of this Notice.

To Ask for Help or Make a Complaint

If you have questions about this notice, want more information, want to request forms for submitting written requests, or want to report a problem about the handling of your protected health information, you may contact:

Office Manager
Emerald City Naturopathic Clinic, Inc. P.S.
1409 NW 85th Street, Seattle, WA 98117
206-781-2206

We respect your right to file a complaint with us or with the U.S. Secretary of Health and Human Services. If you complain, we will not retaliate against you.

Other Disclosures and Uses of Protected Health Information

Notification of Family and Others

• Unless you object, we may release health information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may tell your family or friends your condition and that you are in a hospital. In addition, we may disclose health information about you to assist in disaster relief efforts.
• You have the right to object to this use or disclosure of your information. If you object, we will not use or disclose it. We may ask you to provide a written statement listing persons with whom you wish your health information to be shared, and those to whom you do not wish your information to be given.

Incidental Disclosures

• Emerald City Naturopathic Clinic will make reasonable efforts to avoid incidental disclosures of protected health information.
• Examples of ways in which we work to protect against such disclosures are:
  • having patients check out one at a time at the front desk, with others being asked to wait until called up;
  • keeping patient charts in areas where only appropriate staff have access to them;
  • protecting the anonymity of our patients and the confidentiality of their PHI in conversations in areas where other patients or unauthorized personnel are present or might overhear;
  • asking and gaining your permission before admitting students to observe or assist in your care.

Minors

• If you are a minor who has lawfully provided consent for treatment and you wish for us to treat you as an adult for purposes of access to and disclosure of records related to this treatment, you may notify the doctor or our Office Manager.

• To medical researchers- if the research has been approved and has policies to protect the privacy of your health information. We may also share information with medical researchers preparing to conduct a research project.
• To Funeral Directors/Coroners consistent with applicable law to allow them to carry out their duties.
• To Organ Procurement Organizations (tissue donation and transplant) or persons who obtain, store, or transplant organs.
• To the Food and Drug Administration (FDA) relating to problems with food, supplements, and products.
• To comply with workers’ compensation laws if you make a workers’ compensation claim.
• For Public Health and Safety purposes as allowed or required by law:
  • to prevent or reduce a serious, immediate threat to the health or safety of a person or the public.
  • to public health or legal authorities in order to protect public health and safety.
  • to prevent or control disease, injury, or disability.
  • to report vital statistics such as births or deaths.
• To report suspected Abuse or Neglect to public authorities.
• To Correctional Institutions if you are in jail or prison, as necessary for your health and the health and safety of others.
• For Law Enforcement purposes such as when we receive a subpoena, court order, or other legal process, or you are the victim of a crime.
• For Health and Safety oversight activities. For example, we may share health information with the Department of Health.
• For Disaster Relief Purposes. For example, we may share health information with disaster relief agencies to assist in notification of your condition to family or others.
• For Work-Related Conditions That Could Affect Employee Health. For example, an employer may ask us to assess health risks on a job site.
• To the Military Authorities of U.S. and Foreign Military Personnel. For example, the law may require us to provide information necessary to a military mission.
• In the Course of Judicial/Administrative Proceedings at your request, or as directed by a subpoena or court order.
• For Specialized Government Functions. For example, we may share information for national security purposes.

Other Uses and Disclosures of Protected Health Information

• Uses and disclosures not in this Notice will be made only as allowed or required by law or with your written authorization.

Web Site

• For your benefit, the most updated version of this Notice is posted on our website, effective August 2004.

Effective Date: April 14, 2003