This notice describes how medical information about you can be used and disclosed, and how you can get access to this information. Please review it carefully.

Pediatrics Northwest, PS, respects your privacy. We understand that your personal health information is very sensitive. We will not disclose your information to others unless you tell us to do so, or unless the law authorizes or requires us to do so.

The law protects the privacy of the health information we create and obtain in providing our care and services to you. For example, your protected health information includes your symptoms, test results, diagnoses and treatment, health information from other providers, and billing and payment information relating to these services. Federal and state law allows us to use and disclose your protected health information for purposes of treatment and healthcare operations. State law requires us to get your authorization to disclose this information for payment purposes.

Examples of use and disclosure of protected health information:

  • For treatment:
    • Information obtained by a nurse, physician, nurse practitioner or other member of our healthcare team will be recorded in your medical record and used to help decide what care could be right for you.
    • We might also provide information to others providing you care. 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 can include your diagnoses, procedures performed or recommended care.
  • For healthcare operations:
    • We use your medical records to assess quality and improve services.
    • We could use and disclose medical records to review the qualifications and performance of our healthcare providers and to train our staff.
    • We could contact you to remind you about appointments and give you information about treatment alternatives or other health-related benefits and services.
    • We could contact you to raise funds.
    • We could submit to and/or obtain from a statewide immunization database your individual immunization history.
    • We could use and disclose your information to conduct or arrange for services, including:
      1. Medical quality review by your health plan;
      2. Accounting, legal, risk management and insurance services;
      3. Audit functions, including fraud and abuse detection and compliance programs.

Your health information rights

The health and billing records we create and store are the property of the Pediatrics Northwest, PS. 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, but we will comply with any request granted;
  • Request and receive from us a paper copy of the most current Notice of Privacy Practices for Protected Health Information (“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 disclosures of your health information. The list will not include disclosures to third-party payors. 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:

Diane Harrington, Administrator
316 Martin Luther King Jr. Way, Suite 212
Tacoma, WA 98405

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 any of our offices to pick one up.

Questions, Complaints, and Reports

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

Diane Harrington, Administrator
316 Martin Luther King Jr. Way, Suite 212
Tacoma, WA 98405

If you believe your privacy rights have been violated, you may discuss your concerns with any staff member. You also may deliver a written complaint to Diane Harrington, Administrator, at Pediatrics Northwest, PS. You also may file a complaint with the state at:

Washington State Department of Health
510 4th Ave. W, Suite 404
Seattle, WA 98119

You also may file a complaint with the US Secretary of Health and Human Services. If you complain, we will not retaliate against you.

Notification of family and others

  • Unless you object, we could release health information about you to a friend or family member who is involved in your medical care. We could also give information to someone who helps pay for your care. We could tell your family or friends your condition and that you are in a hospital. In addition, we could disclose health information about you to assist in disaster relief efforts.
  • Mary Bridge Children’s Hospital, Multicare Health Systems, St. Joseph Hospital, St. Francis Hospital and other hospitals’ information could be provided to people who ask for you by name. We could use and disclose the following information in a hospital directory:
  1. Your name
  2. Religion (only to clergy)
  3. General condition, and
  4. Location

You have the right to object to this use or disclosure of your information. If you object, we will not use or disclose it.

Using your personal health information without your consent

We are legally required to use or disclose identifiable health information about you without your consent to meet special report requirement, to facilitate continuity of care, or for public health and other purposes. For example, we provide:

  • Information about your personal health information to other care providers such as physicians, nurses, therapists and others who are involved with your care.
  • Reports to the Food and Drug Administration (FDA).
  • Data for health oversight activities such as auditing or licensure.
  • Reports on communicable diseases.
  • Reports to employers for work-related illness or injures 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.
  • Information to funeral directors/coroners consistent with applicable law to allow them to carry out their duties.
  • Information to organ procurement organizations (tissue donation and transplant) or persons who obtain, store or transplant organs.
  • Reports to medical researchers if the research has been approved and has policies to protect the privacy of our health information. We could also share information with medical researchers preparing to conduct a research project.
  • Communication with designated family members or other individuals whom 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. These might include:

  • For public health and dafety purposes as allowed or required by law:
    1. To prevent or reduce a serious, immediate threat to the health or safety of a person or the public.
    2. To public health or legal authorities.
    3. To protect publish health and safety.
    4. To prevent or control disease, injury or disability.
    5. To report vital statistics such as births or deaths.
    6. To report suspected abuse or neglect to public authorities.
    7. To correctional institutions if you are in jail or prison, as necessary for your health and the health and safety of others.
    8. For law enforcement purposes such as when we receive a subpoena, court order or other legal process, or you are the victim of a crime.
    9. For health and safety oversight activities. For example, we could share health information with the Department of Health.
    10. For disaster relief purposes. For example, we could share health information with disaster relief agencies to assist in notification of your condition to family or others.
    11. For work-related conditions that could affect employee health. For example, an employer could ask us to assess health risks on a job site.
    12. To the military authorities of the United States and foreign military personnel. For example, the law could require us to provide information necessary to a military mission.
    13. In the course of judicial/administrative proceedings at the request of, or as directed by, a subpoena or court order.
    14. For specialized government functions. For example, we could share information for national security purposes

Other uses and disclosures of protected health information

  • We participate in a statewide immunization database (Child Profile). Immunization information including patient’s name, date of birth, vaccine name and lot number are submitted to this database unless you object.
  • Other uses and disclosures not in this Notice will be made only as allowed or required by law or with your written authorization.

Pediatrics Northwest Website

For your benefit, this Notice is posted on our website. The effective date of this Notice is April 14, 2003.