Center for Women’s Health at Evergreen
12303 NE 130th Lane, #500 Kirkland, WA 98034/425-899-4455/fax 425-899-4434

Notice of Privacy Practices

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.

Who will Follow this Notice?

All medical staff, healthcare professionals, staff and authorized personnel employed by The Center for Women’s Health at Evergreen.

The Center for Women’s Health at Evergreen 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 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, diagnosis, treatment, health information from other providers, 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 health care operations.  State law requires us to obtain your authorization to disclose this information for payment purposes.

This notice describes the ways we may use and disclose medical information about you.  It also describes your rights and the obligations regarding the use and disclosure of your medical information.

We are required by law to make sure that medical information that identifies you is kept private, give you this notice of our legal duties and privacy practices, and follow the terms of the notice that is currently in effect.

Examples of Use and Disclosure of Protected Health Information for Treatment, Payment and Health 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 to help decide what care may be right for you.
  • We may also provide information to others providing you care. This will help them stay informed about your care as well as coordinate needed services.
For payment:
  • We request payment from your health insurance plan. Health plans need information from us about your medical care. Information provided to healthcare plans may include your diagnosis, procedures performed, or recommended care. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine if your insurance plan will cover it.
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 contact you about appointments and give you information about alternatives or other health-related benefits and services.
  • We may also share your information with other individuals (such as consultants and billing companies) and organizations that help us with our business activities. If we share your health information with other organizations for this purpose, they must agree to protect your privacy.
  • We may use and disclose your information to conduct or arrange for services, including a medical quality review by your health plan; accounting, legal, risk management and insurance services; or audit functions including fraud and abuse detection and compliance programs.

Examples of Circumstances where we may use or disclose your protected health

information (HPI) without your authorization:

  • Medical Research—if the research has been approved and has 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—consistent with the law to allow them to carry out their duties
  • Organ Procurement Organizations— information may be shared as necessary to facilitate tissue donation and organ transplant.
  • Public Health and Safety— to prevent or reduce a serious immediate threat to the health or safety of a person or the public, information may be given 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 birth or death; to report suspected abuse or neglect to public authorities.
  • Correctional Institutions—if you are in jail or prison, information may be shared as necessary for your health and safety as well as others.
  • Law Enforcement Purposes –in situations where we receive a subpoena, court order, or other legal process, or you are the victim of a crime.
  • Health and Safety Oversight Activities—we may share health information with the Department of Health.
  • Disaster Relief Purposes—your health information may be shared with disaster relief organizations to assist in notification of your condition to family or others.
  • Military Authorities—the law may require us to provide information necessary to a military mission
  • In the Course of a Judicial /Administrative Proceedings—at your request or as directed by a subpoena of court order.
  • Specialized Government functions—we may share information for national security purposes.

Your Health Information Rights

The health and billing records we create and store are the property of The Center for Women’s Health at
Evergreen. 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. We will request that you make your request in writing and we may charge a reasonable fee for the cost of producing and mailing the copies. We have a form available for this type of request.
  • In some cases, have us review a denial of access to your health information.
  • Ask us to change your health information. We will ask that you make your 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 records.
  • At your request, we will give you a list of disclosures of your health information. The list will not include
  • disclosures to third party payers. You may receive this information without charge once every 12 months. We will notify you of the cost involved if you request the information more than once every 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:
The Center for Women’s Health at Evergreen
HIPAA Privacy Officer
425-899-4455

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:

The Privacy Officer
Center for Women’s Health at Evergreen
425-899-4455

If you believe your privacy rights have been violated, you may discuss your concerns with our Privacy officer at the above phone number or in writing to Privacy Officer, The Center for Women’s Health at Evergreen, 12303 NE 130th Lane, Suite 500, Kirkland, WA 98034.  If we cannot resolve your concern, you may also contact the Secretary of the Department of Health and Human Services.  You will not be penalized for filing a complaint.

Other Disclosures and Uses of Protected Health Information

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 medical care. We may tell your family or friends your condition and that you are in a hospital.
You have the right to object to this use or disclosure of this information. If you object, we will not use it or
disclose it.
  • Uses and disclosures not in this Notice will be made only as allowed or required by law or with your written authorization.

Web Site

  • We have a Web site that provides information about us. For your benefit, this notice is on the Web site at this address: www.womenshealthcare.org
Effective Date: 4/14/03

Download the PDF Version