Complete the Request for Access to Protected Health Information form & fax or email to:
For demographic and insurance information please call or email:
A written request is necessary. Please send an encrypted email to:
Questions?
If you have questions regarding medical record requests, call our administrative office at (503) 678-4364.
A written request is necessary. Please send an encrypted email to:
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.
You can complain if you feel we have violated your rights by contacting us using the information on page 1.
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights:
We will not retaliate against you for filing a complaint.
By letter: 200 Independence Avenue, S.W., Washington, D.C. 20201 By phone: 1-877-696-6775 By website: www.hhs.gov/ocr/privacy/hipaa/complaints We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In the case of fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you again.
How do we typically use or share your health information? We typically use or share your information in the following ways:
We can use your health information and share it with other professionals treating you. (Example: A doctor treating you for an injury asks another doctor about your overall health condition.)
We can use and share your health information to run our practice, improve your care, and contact you when necessary. (Example: We use health information about you to manage your treatment and services.)
We can use and share your health information to bill and get payment from health plans or other entities. (Example: We give information about you to your health insurance plan so it will pay for your services.)
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information: www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/
We can share health information about you for certain situations, such as:
We can use or share your information for health research.
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
We can share health information about you with organ procurement organizations.
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
We can use or share health information about you:
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
For more information see:
www.hhs.gov/hipaa/for-individuals/notice-privacy-practices/
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
Effective Date: March 7, 2014 Last updated: 10/02/2024
EMS and Hospital Personnel:
For immediate emergency dispatch, call us 24/7. We’re standing by.
