Kevin F. Montgomery, M.D., F.A.C.S.
Robert Michaelson, M.D., Ph.D., F.A.C.S.
Alana Chock, M.D., F.A.C.S.
Notice of Patient 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. It describes your rights and certain obligations we have for using your health information and informs you about laws which provide special protections for our health information. It tells you how any changes in this notice will be posted and made available.
The law protects the privacy of health information we create and obtain in providing our care and services to you. 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.
Who Will Follow This Notice:
This notice covers the information practices of all healthcare professionals, employees, contract staff, satellite offices, students and volunteers for Northwest Weight Loss Surgery. This notice applies to the health information and health records used for you in these facilities.
Your Personal Health Information:
Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is documented. Typically this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:
• Basis for planning your care and treatment
• Means of communication among the many health professionals who contribute to your care
• Legal document describing the care you received
• Means by which you or a third-party payer can verify that services billed were actually provided
• A source of information for public health officials charged with improving the health of the community
• A tool in educating health professionals
• A source of data for medical research, when approved by the correct oversight authority
• A source of data for facility planning and marketing
• A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve
Understanding what is in your record and how your health information is used helps you to ensure its accuracy, to better understand who, what, when, where and why others may access your health information, and to make a more informed decision when authorizing disclosure to others.
Use and Disclosure Not Requiring Your Authorization
At Northwest Weight Loss Surgery, we may use your health information without your authorization as follows:
We may use your health information for our treatment activities, such as disclosing it to other healthcare providers as helpful to treat you.
Payment: We may use and disclose your health information for our payment activities, such as sending claims to insurance companies.
Healthcare Operations: We may use and disclose your health information to manage our program operations, such as reviewing the quality of services you receive.
Business Associates: We may disclose your health information to organizations that help us with our work, such as the billing service we use to process claims to your health insurance company. We have a written agreement that requires these organizations to use your health information for only the reasons necessary to do the work, and protect it from other uses or disclosures, just like we do.
To Contact You:
We may use the information in your health records to contact you if we have information about treatment or other health-related benefits and services that may be of interest to you.
Additionally, we are legally required to use or disclose identifiable health information about you without your consent to meet special reporting requirements, to facilitate continuity of care, or for public health and other purposes. For example, we provide:
• Reports to the Food and Drug Administration
• Data for health oversight activities such as auditing or licensure
• Reports on communicable diseases
• Reports to employers for work-related illnesses or injuries such as in Workers' Compensation
• Reports on abuse, neglect or domestic violence
• Reports to avert a serious threat to health or safety or to prevent serious harm to an individual
• Communication with designated family members or other individuals who you select as your personal representative about your care
We must provide information when required by law, such as for law enforcement or judicial activities in specific circumstances.
Certain federal and state laws that provide special protections for certain kinds of personal health information call for specific authorizations from you to use or disclose information. When your personal health information falls under these special protections, we will contact you to secure the required authorizations to comply with federal and state laws such as:
• Uniform Health Care Information Act (RCW 70.02)
• Sexually Transmitted Diseases (RCW 70.24.105)
• Drug and Alcohol Abuse Treatment Records (RCW 70.96A.150)
• Mental Health Services for Minors (RCW 71.05.390-690)
• Communicable and Certain Other Diseases Confidentiality (WAC 246-100-016)
• Confidentiality of Alcohol and Drug Abuse Patients (42 CFR Part 2)
If we need your health information for any other reason that has not been described in this notice, we will ask you for your written authorization before using or disclosing any identifiable health information about you. Most important, if you choose to sign an authorization to disclose information, you can revoke that authorization at a later time to stop any future use and disclosure.
Your Individual Rights
You have individual rights over the use and disclosure of your personal health information. You have the right to:
Limit use: You may request in writing that we not use or disclose your information for treatment, payments, and administrative purposes except when specifically authorized by you, when required by law, or in emergency circumstances. We will consider your request but are not legally required to accept it. If we agree to your request we will honor it.
Restrict information to insurance: You have the right to request restriction of information given to your third party payer if you self pay for the services. If you pay in full for services out of your own pocket, you can request that the information regarding the services not be disclosed to your third party payer since no claim is being made against the third party payer.
Receive confidential communications: We may call you to confirm an appointment, and leave a message on your voice mail or with another person. You have the right to receive confidential communication by alternative means or locations. This includes an alternative mailing address or an email address. If this is necessary, please let us know.
Inspect and copy: You have the right to look at your health information and review your record of healthcare. You may request a copy of your health information. Standard copy fees will be assessed. Upon our transition to an Electronic Health Record (EHR) you have a right to obtain a copy of your health information in electronic format.
Request amendments: If you believe that information in your record is incorrect or if important information is missing, you have the right to request that the existing information be amended. We will consider your request but are not legally required to accept it. If we agree to your request we will honor it.
Know about disclosures: You have the right to receive a list of instances where we have disclosed your protected health information. You 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.
Receipt of this notice: You have the right to receive this notice either on paper or electronically. Please let us know if you would like a copy of this notice in another format.
Receive notice of a security breach: Effective September 23, 2009, we are required to notify you if your protected health information has been breached. The notification will occur by first class mail within 60 days of the event. A breach occurs when there has been an unauthorized use or disclosure under HIPAA that compromises the privacy or security of protected health information. The notification requirements under this section only apply if the breach poses a significant risk for financial, reputational, or other harm to you. The notice will contain the following information: (1) a brief description of what happened, including the date of the breach and the date of the discovery of the breach; (2) the steps you should take to protect yourself from potential harm resulting from the breach; and (3) a brief description of what we are doing to investigate the breach, mitigate losses, and to protect against further breaches.
Not every impermissible use or disclosure of protected health information constitutes a reportable breach. The determination of whether an impermissible breach is reportable hinges on whether there is a significant risk of harm to you as a result of impermissible activity. For example, if your protected health information was accidentally shared with an employee of Northwest Weight Loss Surgery who understands their confidentiality obligations, you would not need to be notified of the breach. The key to determining potential harm is whether sufficient information was released that would allow identity theft or harm you because of the likelihood of sharing sensitive health data.
If you are concerned that we have violated your privacy, or you disagree with a decision we made about access to your records, you may discuss this with your physician or the privacy officer either in person or by calling our office at 425-385-2263.
If you are not satisfied with the protection your personal health information, you may contact the Secretary of Health and Human Services if you feel your privacy rights have been violated. Northwest Weight Loss Surgery will not retaliate against a patient for filing a complaint.
When New Uses Are Required
Our Legal Duty: We are required by law to protect the privacy of your information, provide this notice about our information practices, and to follow the information practices that are described in this notice.
Northwest Weight Loss Surgery reserves the right to change the terms of this notice and to make the new notice provisions effective for all the personal health information that it maintains. We may change our policies at any time but with any significant policy change the new notice will be changed, posted, and distributed to our patients. Also, this notice will be promptly revised and distributed whenever there is a material change to the uses or disclosures, your rights, our legal duties or other privacy practices changes. Any such changes will become effective on the date the revised notice is issued. You may request a copy of this notice from us at any time.
This notice is effective as of 04/15/03
This notice was revised on 12/01/10