Privacy Policy

Notice of Privacy Practices

Your Information. Your Rights. Our Responsibilities.

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.

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.


Get an electronic or paper copy
of your medical record

[Protected Health Information (PHI):


  • 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. (This excludes psychotherapy notes and/or PHI subject to law that prohibits access or information compiled in reasonable anticipation of or use in, a civil, criminal, or administrative action or proceeding.)
  • 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.


Ask us to correct your medical record:


  • You can ask us to correct health information about you that you think is incorrect or incomplete as long as we maintain this information. Ask us how to do this. (form1006)
  • We may say “no” to your request, but we’ll tell you why in writing.


Request confidential communications:


  • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
  • We will say “yes” to all reasonable requests. We may ask for information as to how payment will be handled. Ask us how to do this. (form 1014)


Ask us to limit what we use or share:


  • You can ask us not to use or share certain health information for treatment, payment, or our operations. Please discuss restrictions with your physician. (form 1014)
    • 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.


Get a list of those with whom we’ve shared 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 or those family members or friends that have been involved in your care). 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.


Get a copy of this privacy notice:


  • 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.


Choose someone to act for you:


  • 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.
  • Legal documentation must be provided that proves the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated:


  • 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 Secretary of the Department of Health and Human Services , U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 2201 Sixth Avenue-M/S: RX-11 Seattle, WA 98121-1831, calling 206-615-2290, TDD 206-615-2296 or visiting
  • 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. We may ask you to document what you want us to do, and we will follow your instructions.

In these cases, you have
both the right and choice
to tell us to:

  • Share information with your family, close friends, or others involved in your care. (A release must be signed by you.)
  • Share information in a disaster relief situation

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 these cases we never
share your information
unless you give us
written permission:

  • Marketing purposes
  • Sale of your information
  • Most sharing of psychotherapy notes

How do we typically use or share your health information? We typically use or share your health information in the following ways.

Treat You:

  •  We can use your health information
    and share it with other professionals
    who are treating you.
  • Confidential information between
    minor and physician will be kept
    confidential unless authorized for
    release by the patient or deemed by
    physician to affect their care.
Example: A doctor treating you
for an injury asks another doctor
about your overall health

Run our

  • We can use and share your health
    information to run our practice, improve
    your care, and contact you when
Example: We use health
information about you to manage
your treatment and services.

Bill for your

  • 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.

How else can we use or share your health information? 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 see:

Help with public health
and safety issues:


  • We can share health information about you for certain situations
    such as:
    • Preventing disease
    • Helping with product recalls
    • Reporting adverse reactions to medications
    • Reporting births/deaths
    • Reporting suspected abuse, neglect, or domestic violence
    • Preventing or reducing a serious threat to anyone’s health or

Do Research:


  • We can use or share your information for health research.

Comply with the law:


  • We will share information about you if state, local 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.

Respond to organ and
tissue donation requests:


  • We can share health information about you with organ
    procurement organizations.

Work with a medical
examiner or funeral director:


  • We can share health information with a coroner, medical
    examiner, or funeral director when an individual dies.

Address workers’
compensation, law
enforcement, and other
government requests:


  • We can use or share health information about you:
    • For workers’ compensation claim
    • For law enforcement purposes or with a law enforcement
    • If you are an inmate of a correctional facility & your physician
      created or received your protected health information in the
      course of providing care to you.
    • With health oversight agencies for activities authorized by law
    • For special government functions such as military, national
      security, and presidential protective services

Respond to lawsuits and
legal action:


  •  We can share health information about you in response to a
    court or administrative order, or in response to a subpoena



  • We may contact you by phone & leave a message on the
    phone numbers you have provided us regarding appointment
    reminders, test results etc..
  • If we are unable to obtain consent from you due to a
    communication barrier the physician may determine to share
    your information without consent if it would affect your



  • We may post patient/family pictures in the clinic that have
    been given to us by the patient/family for this purpose

  • We do not create or manage a hospital directory.
  • We do not create psychotherapy notes at this practice.
  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
  • We will not use or share your information other than as described here unless youtell us we can in writing. Let us know in writing if you change your mind.

For more information see:


Changes to the Terms of This Notice:

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 website.

Please contact the East Portland Pediatric Clinic, PC Privacy Officer at 503-255-3544 if you have questions.