NOTICE OF PRIVACY PRACTICES
As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA)
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THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS
PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GAIN ACCESS TO YOUR
INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.
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PLEASE REVIEW THIS NOTICE CAREFULLY.
A. OUR COMMITMENT TO YOUR PRIVACY:
Our practice is dedicated to maintaining the privacy of your individually identifiable health information
(IIHI). In conducting our business, we will create records regarding you and the treatment and services we
provide to you. We are required by law to maintain the confidentiality of health information that identifies
you. We are also required by law to provide you with this notice of our legal duties and the privacy practices
that we maintain in our practice concerning your IIHI. By federal and state law, we must follow the terms of
the notice of privacy practices that we have in effect at the time.
We realize that these laws are complicated, but we must provide you with the following important
information:
• how we may use and disclose your IIHI
• your privacy rights in your IIHI
• our obligations concerning the use and disclosure of your IIHI
The terms of this notice apply to all records containing your IIHI that are created or retained by our practice.
We re serve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this
notice will be effective for all of your records that our practice has created or maintained in the past, and for
any of your records that we may create or maintain in the future. Our practice will always post a copy of our
current Notice in our office in a visible location, and you may request a copy of our most current Notice at
any time.
B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
Rooted Direct Primary Care
Attn: Privacy Officer
106 N Howard St.
Newberg, OR 97132
503-714-6645
C. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION
(IIHI) IN THE FOLLOWING WAYS:
The following categories describe the different ways in which we may use and disclose your IIHI, unless you
object:
1. Treatment. Our practice may use your IIHI to treat you. For example, we may ask you to have laboratory
tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use
your IIHI in order to write a prescription for you, or we might disclose your IIHI to a pharmacy when we
order a prescription for you. Many of the people who work for our practice—including, but not limited to,
our doctors and nurses—may use or disclose your IIHI in order to treat your or to assist others in your
treatment. Additionally, we may disclose your IIHI to others who may assist in your care, such as other
healthcare providers, your spouse, your children or your parents.2. Payment. Our practice may use and disclose your IIHI in order to bill and collect payment for the
services and items you may receive from us. For example, we may use and disclose your IHII to obtain
payment from third parties that may be responsible for such costs, such as family members. Also, we may
use your IIHI to bill you directly for services and items.
3. Health Care Operations. Our practice may use and disclose your IIHI to operate our business. As
examples of the ways in which we may use and disclose your information for our operations, our practice
may use your IIHI to evaluate the quality of care you received from us, to develop protocols and clinical
guidelines, to develop training programs, and to aid in 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.
4. Appointment Reminders. Our practice may use and disclose your IIHI to contact you and remind you of
an appointment.
5. Treatment Options. Our practice may use and disclose your IIHI to inform you of potential treatment
options or alternatives.
6. Health-Related Benefits and Services. Our practice may use and disclose your IIHI to inform you of
health-related benefits or services that may be of interest to you.
7. Release of Information to Family/Friends. Our practice may release your IIHI to a friend or family
member that is involved in your care, or who assists in taking care of you. For example, a parent or
guardian may ask that a babysitter take their child to the family doctor’s office for treatment of a cold. In
this example, the babysitter may have access to this child’s medical information.
8. Disclosures Required by Law. Our practice will use and disclose your IIHI when we are required to do
so by federal, state, or local law.
D. USE AND DISCLOSURE OF YOUR IIHI IN CERTAIN SPECIAL CIRCUMSTANCES:
The following categories describe unique scenarios in which we may use or disclose your identifiable health
information:
1. Public Health Risks. Our practice may disclose your IIHI to public health authorities that are
authorized by law to collect information for the purpose of:
• maintaining vital records, such as births and deaths
• reporting child abuse or neglect
• preventing or controlling disease, injury, or disability
• notifying a person regarding potential exposure to a communicable disease
• notifying a person regarding a potential risk for spreading or contracting a disease or
condition
• reporting reactions to drugs or problems with products or devices
• notifying individuals if a product or device they may be using has been recalled
• notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse
or neglect of an adult patient (including domestic violence); however, we will only disclose
this information if the patient agrees or we are required or authorized by law to disclose this
information
• notifying your employer under limited circumstances related primarily to workplace injury or
illness or medical surveillance
2. Health Oversight Activities. Our practice may disclose your IIHI to a health oversight agency for
activities authorized by law. Oversight activities can include, for example, investigations, inspections,
audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or
actions; or other activities necessary for the government to monitor government programs,
compliance with civil rights laws and the health care system in general.
3. Lawsuits and Similar Proceedings. Our practice may use and disclose your IIHI in response to a
court or administrative order if you are involved in a lawsuit or similar proceeding. We also maydisclose your IIHI in response to a discovery request, subpoena, or other lawful process by another
party involved in the dispute, but only if we have made an effort to inform you of the request or to
obtain an order protecting the information the party has requested.
4. Law Enforcement. We may release IIHI if asked to do so by a law enforcement official:
• regarding a crime victim in certain situations, if we are unable to obtain the person’s
agreement
• concerning a death we believe has resulted from criminal conduct
• regarding criminal conduct at our offices
• in response to a warrant, summons, court order, subpoena or similar legal process
• to identify/locate a suspect, material witness, fugitive or missing person
• in an emergency, to report a crime (including the location or victim(s) of the crime, or the
description, identity or location of the perpetrator)
5. Deceased Patients. Our practice may release IIHI to a medical examiner or coroner to identify a
deceased individual or to identify the cause of death. If necessary, we may also release information in
order for funeral directors to perform their jobs.
6. Organ and Tissue Donation. Our practice may release your IIHI to organizations that handle organ,
eye or tissue procurement or transplantation, including organ donation banks, as necessary to
facilitate organ or tissue donation and transplantation if you are an organ donor.
7. Research. Our practice may use and disclose your IIHI for research purposes in certain limited
circumstances. We will obtain your written authorization to use your IIHI for research purposes
except when: (a) our use or disclosure was approved by an Institutional Review Board or a Privacy
Board; (b) we obtain the oral or written agreement of a researcher that (i) the information being
sought is necessary for the research study; (ii) the use or disclosure of your IIHI is being used only for
the research and (iii) the researcher will not remove any of your IIHI from our practice; or (c) the IIHI
sought by the researcher only relates to decedents and the researcher agrees either orally or in writing
that the use or disclosure is necessary for the research and, if we request it, to provide us with proof of
death prior to access to the IIHI of the decedents.
8. Serious Threats to Health or Safety. Our practice may use and disclose your IIHI when necessary to
reduce or prevent a serious threat to your health and safety or the health and safety of another
individual or the public. Un der these circumstances, we will only make disclosures to a person or
organization able to help prevent the threat.
9. Military. Our practice may disclose your IIHI if you are a member of U.S. or foreign military forces
(including veterans) and if required by the appropriate authorities.
10. National Security. Our practice may disclose your IIHI to federal officials for intelligence and
national security activities authorized by law. We may also disclose your IIHI to federal officials in
order to protect the President, other officials or foreign heads of state, or to conduct investigations.
11. Inmates. Our practice may disclose your IIHI to correctional institutions or law enforcement officials
if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes
would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and
security of the institution, and/ or (c) to protect your health and safety or the health and safety of other
individuals.
12. Workers’ Compensation. Our practice may release your IIHI for workers’ compensation and similar
programs.
E. YOUR RIGHTS REGARDING YOUR IIHI:
The health and billing records we maintain are the physical property of Rooted Direct Primary Care. The
information in it, however, belongs to you. You have a right to:
1. Confidential Communications. You have the right to request that our practice communicate with
you about your health and related issues in a particular manner or at a certain location. For instance,you may ask that we contact you at home, rather than work. In order to request a type of confidential
communication, you must make a written request to the Privacy Officer, specifying the requested
method of contact, or the location where you wish to be contacted. Our practice will accommodate
reasonable requests. You do not need to give a reason for your request.
2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your
IIHI for treatment, payment or health care operations. Additionally, you have the right to request that
we restrict our dis closure of your IIHI to only certain individuals involved in your care or the
payment for your care, such as family members and friends. We are not required to agree to your
request; however, if we do agree, we are bound by our agreement except when otherwise required by
law, in emergencies, or when the information is necessary to treat you. In order to request a restriction
in our use or disclosure of your IIHI, you must make your request in writing to the Privacy Officer.
Your request must describe in a clear and concise fashion:
a. the information you wish restricted;
b. whether you are requesting to limit our practice’s use, disclosure or both; and
c. to whom you want the limits to apply.
3. Inspection and Copies. You have the right to inspect and obtain a copy of the IIHI that may be used
to make decisions about you, including patient medical records and billing records, but not including
psychotherapy notes. You must submit your request in writing to the Privacy Officer in order to
inspect and/or obtain a copy of your IIHI. Our practice may charge a fee for the costs of copying,
mailing, labor and supplies associated with your request. Our practice may deny your request to
inspect and/or copy in certain limited circumstances; however, you may request a review of our
denial. Another licensed health care professional chosen by us will conduct reviews.
4. Amendment. You may ask us to amend your health information if you believe it is incorrect or
incomplete, and you may request an amendment for as long as the information is kept by or for our
practice. To request an amendment, your request must be made in writing and submitted to the
Privacy Officer. You must provide us with a reason that supports your request for amendment. Our
practice will deny your request if you fail to submit your request (and the reason supporting your
request) in writing. Also, we may deny your request if you ask us to amend information that is in our
opinion: (a) accurate and complete; (b) not part of the IIHI kept by or for the practice; (c) not part of
the IIHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless
the individual or entity that created is not available to amend the information.
5. Accounting of Disclosures. All of our patients have the right to request an “accounting of
disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice
has made of your IIHI for non-treatment or operations purposes. Use of your IIHI as part of the
routine patient care in our practice is not required to be documented. For example, the doctor sharing
information with the nurse. In order to obtain an accounting of disclosures, you must submit your
request in writing to the Privacy Officer. All requests for an “accounting of disclosures” must state a
time period, which may not be longer than six (6) years from the date of disclosure and may not
include dates before April 14, 2003. The first list you request within a 12-month period is free of
charge, but our practice may charge you for additional lists within the same 12-month period. Our
practice will notify you of the costs involved with additional requests, and you may withdraw your
request before you incur any costs.
6. Right to a Paper Copy of this Notice. You are entitled to receive a paper copy of our notice of
privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper
copy of this notice, contact the Privacy Officer.
7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a
complaint with our practice or with the Secretary of the Department of Health and Human Services.
To file a complaint with our practice, contact:
Rooted Direct Primary Care
Attn: Privacy Officer106 N Howard St.
Newberg, OR 97132
503-714-6645
All complaints must be submitted in writing. You will not be penalized for filing a complaint.
8. Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your
written authorization for uses and disclosures that are not identified by this notice or permitted by
applicable law. Any authorization you provide to us regarding the use and disclosure of your IIHI may
be revoked at any time in writing. After you revoke your authorization, we will no longer use or
disclose your IIHI for the reasons described in the authorization. Please note: we are required to retain
records of your care.
Again, if you have questions regarding this notice or our health information privacy policies, please contact
the Privacy Officer listed above.