PRIVACY STATEMENT

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.

Providers and staff at Interlake Psychiatric Associates, PLLC respect your privacy. We understand that your personal health information is very sensitive. The law protects the privacy of the health information we create and obtain in providing care and services to you. 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. We will not use or disclose your health information to others without your authorization, except as described in this Notice, or as required by law.

YOUR HEALTH INFORMATION RIGHTS

The health and billing records we create, and store are the property of your provider. The protected health information in it, however, generally belongs to you. You have a right to:

▪ Receive, read, and ask questions about this Notice.

▪ Ask us to restrict certain uses and disclosures. You must deliver this request in writing to us. We are not required to grant the request unless the request is to restrict disclosure of your protected health information to a health plan for payment or health care operations and the protected health information is about a service or treatment for which you paid directly.

▪ Request and receive from us a paper copy of the most current Notice of Privacy Practices (“Notice”).

▪ Request that you be allowed to see and get a copy of your protected health information. You may make this request in writing. We have a form available for this type of request.

▪ Have us review a denial of access to your health information—except in certain circumstances.

▪ Ask us to change your health information. You may give us this request in writing. You may write a statement of disagreement if your request is denied. It will be stored in your medical record and included with any release of your records.

▪ When you request, we will give you a list of certain disclosures of your health information. The list will not include disclosures for treatment, payment, or health care operations. 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.

▪ Ask that your health information be given to you by another means or at another location. Please sign, date, and give us your request in writing.

▪ 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 it. Sometimes, you cannot cancel an authorization if its purpose was to obtain insurance.

For help with these rights during normal business hours, please contact:

Anna Lawrence, Practice Administrator

Email: alawrence@interlakepsychiatry.com; Phone: 425-462-9511, ext. 101

OUR RESPONSIBILITIES

We are required to:

▪ Keep your protected health information private.

▪ Give you this Notice.

▪ Follow the terms of this Notice. We have the right to change our practices regarding the protected health information we maintain. If we make changes, we will update this Notice. You may receive the most recent copy of this Notice by calling and asking for it or by visiting our office to pick one up.

To ask for help or complain:

If you have questions, want more information, or want to report a problem about the handling of your protected health information, you may contact:

Anna Lawrence, Practice Administrator

Email: alawrence@interlakepsychiatry.com; Phone: 425-462-9511, ext. 101

If you believe your privacy rights have been violated, you may discuss your concerns with any staff member. You may also deliver a written complaint to Anna Lawrence, Practice Administrator or your provider at Interlake Psychiatric Associates, PLLC. You may also file a complaint with the Department of Health and Human Services Office for Civil Rights (OCR).

We respect your right to file a complaint with us or with the OCR. If you complain, we will not retaliate against you.

HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION

Under the law, we may use or disclose your protected health information under certain circumstances without your permission. The following categories describe the different ways we may use and disclose your protected health information. For each category, we will explain what we mean and give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose health information will fall within one of the categories.

Examples of uses and disclosures of protected health information for treatment, payment, and health care 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 by members of our health care team to help decide what care may be right for you.

• We may also provide information to health care providers outside our practice who are providing you care or for a referral. This will help them stay informed about your care.

For payment:

• We request payment from your health insurance plan. 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 or the person you tell us is responsible for paying for your care if it is not covered by your health insurance plan.

For health care operations:

• We may 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 use and disclose your information to conduct or arrange for services, including:

• Medical quality review by your health plan,

• Accounting, legal, risk management, and insurance services; and

• Audit functions, including fraud and abuse detection and compliance programs

Statements about certain uses and disclosures:

• We may contact you to remind you about appointments.

• We may use and disclose your health information to give you information about treatment alternatives or other health related benefits and services.

• We may contact you to raise funds. If we contact you for fundraising, we will also provide you with a way to opt-out of receiving fundraising requests in the future.

Some of the other ways that we may use or disclose your protected health information without your authorization are as follows:

• Required by law: We must make any disclosure required by state, federal, or local law.

• Business Associates: We contract with individuals and entities to perform jobs for us or to provide certain types of services that may require them to create, maintain, use, and/or disclose your health information. We may disclose your health information to a business associate, but only after they agree in writing to safeguard your health information. Examples include billing services, accountants, and others who perform health care operations for us.

• 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. 

• Public health and safety purposes: As permitted or required by law, we may disclose protected health information:

•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.

•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.

• Research: We may disclose protected health information to researchers if the research has been approved by an institutional review board or a privacy board and there are policies to protect the privacy of your health information. We may also share information with medical researchers preparing to conduct a research project.

• Coroners, medical examiners, and funeral directors: We may disclose protected health information to funeral

directors and coroners consistent with applicable law to allow them to carry out their duties.

• Organ-procurement organizations: Consistent with applicable law, we may disclose protected health information to organ-procurement organizations (tissue donation and transplant) or persons who obtain, store, or transplant organs.

• Food and Drug Administration (FDA): For problems with food, supplements, and products, we may disclose protected health information to the FDA or entities subject to the jurisdiction of the FDA.

• Workplace injury or illness: Washington State law requires the disclosure of protected health information to the Department of Labor and Industries, the employer, and the payer (including a self-insured payer) for workers’ compensation and for crime victims’ claims. We also may disclose protected health information for work-related conditions that could affect employee health; for example, an employer may ask us to assess health risks on a job site.

• Correctional institutions: If you are in jail or prison, we may disclose your protected health information as necessary for your health and the health and safety of others.

• Law enforcement: We may disclose protected health information to law enforcement officials as required by law, such as reports of certain types of injuries or victims of a crime, or when we receive a warrant, subpoena, court order, or other legal process.

• Government health and safety oversight activities: We may disclose protected health information to an oversight agency that may be conducting an investigation. For example, we may share health information with the Department of Health.

• Disaster relief: We may share protected health information with disaster relief agencies to assist in notification of your condition to family or others.

• Military, Veteran, and Department of State: We may disclose protected health information 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.

• Lawsuits and disputes: We are permitted to disclose protected health information in the course of judicial/administrative proceedings at your request, or as directed by a subpoena or court order.

• National Security: We are permitted to release protected health information to federal officials for national security purposes authorized by law.

• Deidentifying information: We may use your protected health information by removing any information that could be used to identify you.

SPECIAL AUTHORIZATIONS

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)

• Drug and Alcohol Abuse Treatment Records (RCW 70.96A)

• Mental Health Services (RCW 71.05)

• Mental Health Services for Minors (RCW 71.34)

If we need your health information for any other reason that has not been described in this notice, we will ask 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.

Psychotherapy Notes:

Notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of a conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. An authorization to use or disclose psychotherapy notes is required except if used by the originator of the notes for treatment, to a person or persons reasonably able to prevent or lessen the threat (including the target of the threat), if the originator believes in good faith that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public, if the notes are to be used in the course of training students, trainees or practitioners in mental health; to defend a legal action or any other legal proceeding brought forth by the patient; when used by a medical examiner or coroner; for health oversight activities of the originator; or when required by law.