Notice of Privacy Practices

Your Rights

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

Get an Electronic or Paper Copy of Your Medical Record

You may ask to see or obtain an electronic or paper copy of your medical record and other health information we maintain about you.

Under Washington law, after receiving a written request, we will generally make the requested information available as promptly as circumstances require and no later than 15 working days after receiving the request.

If unusual circumstances delay the request, we may provide written notice explaining the delay and identifying the earliest date the information will be available, which will generally be no later than 21 working days after receiving the request.

We may charge a reasonable fee when permitted by applicable law.

To request your records, contact:

Lisa Hope, Clinic Director and Privacy Officer
Phone: 360.737.9665

Ask Us to Correct Your Medical Record

You may ask us to correct health information about you that you believe is incorrect or incomplete.

We may deny your request in certain circumstances permitted by law. If we deny your request, we will explain the decision in writing and provide information regarding any rights available to you.

Contact Lisa Hope, our Privacy Officer, to learn how to submit an amendment request.

Request Confidential Communications

You may ask us to contact you in a specific way.

For example, you may ask us to:

• Call only a particular telephone number
• Contact you at work instead of home
• Send mail to a different address
• Use another reasonable method of communication

We will accommodate reasonable requests as required by law.

Ask Us to Limit What We Use or Share

You may ask us not to use or share certain health information for treatment, payment, or our health-care operations.

We are not always required to agree to your request.

If we agree to a restriction, we will comply with it except where disclosure is otherwise permitted or required, including certain emergency circumstances.

If you pay for a health-care service or item completely out-of-pocket, you may ask us not to disclose information about that service to your health insurer for payment or health-care operations. We will honor such a request when required by law unless disclosure is otherwise legally required.

Get a List of Certain Disclosures

You may ask for an accounting of certain disclosures of your health information made during the six years before the date of your request.

The accounting generally does not include certain disclosures, including many disclosures made:

• For treatment
• For payment
• For health-care operations
• Directly to you
• Pursuant to your authorization
• To persons involved in your care when permitted by law
• For certain other purposes excluded by applicable law

We will provide one accounting within a 12-month period without charge. We may charge a reasonable, cost-based fee for additional requests when permitted by law.

Get a Copy of This Notice

You may request a paper copy of this Notice at any time, even if you previously agreed to receive it electronically.

We will provide a copy promptly.

Choose Someone to Act for You

If another person has legal authority to act for you, such as:

• A parent
• Legal guardian
• Person holding an appropriate medical power of attorney
• Other legally authorized personal representative

that person may exercise rights concerning your health information as permitted by law.

We may verify that person’s authority before acting on a request.

File a Complaint if You Believe Your Rights Were Violated

You may complain if you believe we violated your privacy rights.

You may contact:

Lisa Hope, Privacy Officer
Dr. Ibolit
221A NE 104th Ave, Suite 205, Vancouver, WA 98664
360.737.9665

You may also file a complaint with the:

U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue SW
Washington, DC 20201
Phone: 1-877-696-6775

We will not retaliate against you for filing a privacy complaint.

Your Choices

For certain health information, you may tell us what you prefer concerning how we share information.

If you have a clear preference concerning the situations described below, tell us what you want us to do and we will follow your instructions as required by law.

Family, Friends, and Others Involved in Your Care

You may tell us whether we may share relevant health information with:

• Family members
• Close friends
• Caregivers
• Other people involved in your care
• People involved in payment for your care

If you are unable to tell us your preference, we may share information if permitted by law and if we reasonably believe the disclosure is in your best interest.

We may also share information when necessary to prevent or reduce a serious and imminent threat to health or safety, when permitted by law.

Disaster Relief

We may share limited information with an organization assisting in disaster-relief efforts when permitted by law.

Marketing

We will obtain your written permission before using or sharing your protected health information for marketing purposes when authorization is required by law.

Sale of Your Information

We will not sell your protected health information without an authorization that specifically permits the sale when such authorization is required by law.

Psychotherapy Notes

If we maintain psychotherapy notes subject to special HIPAA protections, most uses and disclosures of those notes require your written authorization unless an exception under applicable law applies.

Fundraising

If we contact you as part of an authorized fundraising effort, you may tell us not to contact you again.

If we maintain substance-use-disorder records protected by 42 CFR Part 2 and propose to use those records for fundraising, we will provide any additional notice and choice required by law.

How We Typically Use or Share Your Health Information

We typically use or share health information in the following ways.

Treat You

We may use your health information and share it with health-care professionals who are treating you.

For example, we may share relevant information with:

• Chiropractors
• Massage therapists
• Rehabilitation providers
• Imaging providers
• Physicians
• Other health-care professionals involved in your treatment

Run Our Organization

We may use and share your health information to operate our practice, improve patient care, manage services, train staff, coordinate treatment, conduct quality-review activities, and contact you when necessary.

For example, members of our care team may review information about your treatment to coordinate services or evaluate the quality of care provided.

Bill for Your Services

We may use and share your health information to bill and obtain payment from:

• Auto insurance carriers
• Health insurance plans
• Other insurers
• Claims administrators
• Other entities responsible for payment

For example, we may provide information about services you received so that an insurance company can process payment.

Coordinate Accident-Related Care

Because Dr. Ibolit provides care to patients injured in automobile accidents, we may use or disclose health information when permitted by law to coordinate matters related to your care, including:

• Insurance verification
• Treatment coordination
• Outside referrals
• Imaging referrals
• Medical documentation
• Payment
• Case-related administrative communication

Communicate With Your Attorney

With your authorization, or when otherwise permitted or required by law, we may disclose relevant health information to your attorney or authorized legal representative.

Examples may include:

• Medical records
• Treatment documentation
• Billing records
• Progress information
• Responses to authorized requests

Your attorney’s involvement does not provide unlimited access to your medical information. We will disclose information only when authorized or otherwise permitted by law.

Dr. Ibolit does not provide legal advice and does not guarantee the outcome of a legal claim.

Other Ways We May Use or Share Your Health Information

We are permitted or required by law to use or disclose health information in certain other circumstances. These disclosures are subject to legal conditions and limitations.

Help With Public Health and Safety

We may disclose health information for certain public-health and safety activities, including:

• Preventing or controlling disease
• Reporting certain injuries or conditions
• Reporting adverse reactions to medications or products
• Assisting with product recalls
• Reporting suspected abuse, neglect, or domestic violence when permitted or required by law
• Preventing or reducing a serious threat to health or safety

Research

We may use or disclose health information for health research when applicable legal requirements and protections have been satisfied.

Comply With the Law

We will disclose information when federal, Washington State, or other applicable law requires us to do so.

We may also disclose information to the U.S. Department of Health and Human Services when required to demonstrate compliance with federal privacy law.

Organ and Tissue Donation

When applicable and permitted by law, we may disclose health information to organizations involved in organ, eye, or tissue donation and transplantation.

Coroners, Medical Examiners, and Funeral Directors

When legally permitted, we may disclose health information to:

• Coroners
• Medical examiners
• Funeral directors

for purposes authorized by law.

Workers’ Compensation

We may use or disclose health information as authorized or required for workers’ compensation claims and similar programs.

Law Enforcement and Government Requests

When legally permitted or required, we may disclose health information:

• For certain law-enforcement purposes
• To health-oversight agencies
• For authorized audits, inspections, investigations, or licensure activities
• For certain military or national-security functions
• For other governmental functions authorized by law

Lawsuits and Legal Proceedings

We may disclose health information in response to lawful legal process, such as:

• Court orders
• Administrative orders
• Subpoenas
• Discovery requests
• Other legally authorized requests

We will comply with applicable federal and Washington privacy protections before making such disclosures.

Substance Use Disorder Records

To the extent that we receive or maintain substance-use-disorder patient records protected by 42 CFR Part 2, additional confidentiality protections apply.

We will not use or disclose information from such records in civil, criminal, administrative, or legislative investigations or proceedings against you unless:

1. You provide written consent that satisfies applicable legal requirements; or
2. The use or disclosure is authorized by a court order and subpoena as required by law.

These protections apply in addition to other privacy protections described in this Notice.

Washington State Privacy Protections

Washington law provides additional protections for patient health-care information.

Except where disclosure is otherwise authorized or required by law, Washington health-care providers generally may not disclose health-care information about a patient without written authorization.

When Washington law provides greater privacy protection than federal law, we will follow the more protective applicable requirement.

Washington Notice of Information Practices

We keep a record of the health-care services we provide to you.

You may ask us to see and copy that record. You may also ask us to correct that record.

We will not disclose your health-care record to others unless you direct us to do so or unless the law authorizes or requires us to do so.

You may review your record or obtain additional information about your records by contacting:

Lisa Hope, Clinic Director and Privacy Officer
Phone: 360.737.9665

Our Responsibilities

We are required by law to:

• Maintain the privacy and security of your protected health information
• Follow the duties and privacy practices described in this Notice
• Provide you with a copy of this Notice
• Notify you as required by law if a breach occurs that may have compromised the privacy or security of your information
• Respect the privacy rights described in this Notice
• Obtain written authorization before using or disclosing your health information when authorization is required by law

We will not use or share your health information other than as described in this Notice unless you give us permission in writing or another law permits or requires the use or disclosure.

If you provide written authorization, you may revoke that authorization in writing at any time, except to the extent that we have already acted in reliance on it or applicable law otherwise provides.

Changes to the Terms of This Notice

We may change the terms of this Notice.

Any revised Notice may apply to all protected health information we maintain, including information created or received before the revised Notice became effective.

When material changes are made, the updated Notice will be:

• Available upon request
• Available at our clinic
• Posted on our website
• Provided in another manner when required by law

The Effective Date at the top of this Notice will identify the current version.

Record Retention

Washington rules require chiropractors practicing in Washington to maintain patient treatment records, including relevant treatment plans, charts, histories, correspondence, financial information, and billing records.

Such chiropractic treatment records must generally be retained for at least five years.

Other laws, regulations, professional requirements, or circumstances may require records to be maintained for a longer period.

Questions or Complaints

If you have questions about this Notice, our privacy practices, your medical records, or your privacy rights, contact:

Lisa Hope, Privacy Officer
Dr. Ibolit

Legal name: Manual Medicine & Rehabilitation Center, P.C.
Address: 221A NE 104th Ave, Suite 205, Vancouver, WA 98664
Phone: 360.737.9665

You may also file a privacy complaint with the U.S. Department of Health and Human Services Office for Civil Rights.

We will not retaliate against you for exercising your privacy rights or filing a complaint.