DARIN DAVIDSON, M.D. CONSULTING, PLLC
HIPAA NOTICE OF PRIVACY PRACTICES
This Notice Describes How HEALTH Information About You May Be Used and Disclosed and How You Can Get Access to This Information. Please Review THIS NOTICE Carefully.
About this Notice
This Notice will tell you about the ways Darin Davidson, M.D. Consulting, PLLC (the “Practice”) may use and disclose your healthcare information. This Notice also describes your rights and certain obligations the Practice has regarding the use and disclosure of your healthcare information. Although the Practice is not a covered entity under the Health Insurance Portability and Accountability Act, the Practice is required by Washington State law to maintain the privacy of healthcare information that identifies you.
Disclosures the Practice May Make Without Your Authorization
Treatment; Payment; Health Care Operations: Federal and state law allows the Practice to use and disclose your healthcare information in order to provide health care services to you, as well as to bill and collect payments for the services provided to you. For example, the Practice may disclose your healthcare information to those involved in your treatment. the Practice may also disclose your healthcare information to health plans or other responsible parties to receive payment for the services the Practice provides to you. Additionally, the Practice may disclose your healthcare information as necessary in connection with its health care operations. For example, the Practice may use your healthcare information for its internal quality assurance purposes.
Required or Permitted by Law: The Practice may use or disclose healthcare information when the Practice is required or permitted to do so by law. For example, the Practice may disclose healthcare information to appropriate authorities if the Practice reasonably believes that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. The Practice may also disclose your healthcare information to avert a serious threat to your health or safety or the health or safety of others. Other disclosures that may be permitted or required by law include disclosures for the following purposes: public health activities; health oversight activities; in response to a court or administrative order, or in response to a subpoena; research when approved by an institutional review board; workers’ compensation claims; for special government functions such as military, national security, and presidential protective services; organ procurement organizations; coroners; medical examiners; funeral directors; and correctional institutions.
Disclosures for Which You May Object
Family Members: You have the right to direct the Practice to share healthcare information with your family, close friends, or others involved in your care. If you are not able to tell the Practice your preference, for example if you are unconscious, the Practice may share your information with these individuals if the Practice believe it is in your best interest.
Uses and Disclosures Requiring Your Authorization
The Practice will never share your healthcare information for the following purposes unless you give the Practice written authorization, subject to the related definitions and exceptions set forth in applicable state and federal law:
- Marketing purposes
- Sale of your healthcare information
- Most sharing of psychotherapy notes, although the Practice does not maintain psychotherapy notes
Other Uses and Disclosures
Uses and disclosures other than those described in this Notice will only be made with your written authorization. You may revoke or modify your authorization at any time by writing. Please note that your revocation or modification may not be effective in some circumstances, such as when the Practice has already taken action relying on your authorization.
Your Rights Regarding Your PHI
Right to Inspect and Copy: You may request access to your healthcare information in order to inspect and obtain copies of such information. All requests for access must be made in writing. Under limited circumstances, the Practice may deny access to your records. The Practice may charge a reasonable, cost-based fee for providing you with access to your records.
Right to Alternative Communications: You may request, and the Practice will accommodate, any reasonable written request for you to receive healthcare information by alternative means of communication or at alternative locations.
Right to Request Restrictions: You have the right to request a restriction on healthcare information the Practice use or disclose for treatment, payment or health care operations. You must request any such restriction in writing addressed to Darin Davidson, M.D. at email@example.com. The Practice is not required to agree to any such restriction you may request, except if your request is to restrict disclosing healthcare information to a health plan for the purpose of carrying out payment or health care operations, the disclosure is not otherwise required by law, and the healthcare information pertains solely to a health care item or service which has been paid in full by you or another person or entity on your behalf.
Right to Accounting of Disclosures: Upon written request, you may obtain an accounting of disclosures of healthcare information made by the Practice in the last six years, subject to certain restrictions and limitations.
Right to Request Amendment: You have the right to request that the Practice amend your PHI. Your request must be in writing, and it must explain why the information should be amended. The Practice may deny your request under certain circumstances.
Right to Obtain Notice: You have the right to obtain a paper copy of this Notice by submitting a request to Darin Davidson, M.D. at firstname.lastname@example.org at any time.
Right to Receive Notification of a Breach: The Practice is required to notify you if the Practice discovers a breach of your unsecured PHI, according to applicable requirements under federal law.
Questions and Complaints. If you desire further information about your privacy rights or are concerned that the Practice has violated your privacy rights, you may contact Darin Davidson, M.D. at email@example.com. You may also file a written complaint with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. The Practice will not retaliate against you if you file a complaint with the Director or with Practice.
Effective Date and Changes to this Notice
Effective Date: This Notice is effective on May 6, 2019.
Changes to this Notice: The Practice may change the terms of this Notice at any time. If the Practice changes this Notice, the Practice may make the new notice terms effective for all healthcare information that the Practice maintains, including any information created or received prior to issuing the new notice. If the Practice changes this Notice, the Practice will post the revised notice on its web site at http://www.darindavidson.com. You may also obtain any revised notice by contacting Darin Davidson, M.D. at firstname.lastname@example.org.
Acknowledgement of Receipt of Notice of Privacy Practices
By my signature below I, ___________________________________, acknowledge that I received a copy of the Notice of Privacy Practices for Darin Davidson, MD Consulting, PLLC.
Signature of patient (or personal representative) Date
If this acknowledgment is signed by a personal representative on behalf of the patient, complete the following:
Personal Representative’s Name: ___________________________________________
Relationship to Patient: ___________________________________________