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

IF YOU HAVE ANY QUESTIONS ABOUT THIS
NOTICE,PLEASE CONTACT OUR PRIVACY OFFICER
AT OUR OFFICE:

741 N.E.6TH ST.
GRANTS PASS,OR 97526

WHO WILL FOLLOW THIS NOTICE
This notice describes the information privacy practices
followed by our employees,staff and other office
personnel.

YOUR HEALTH INFORMATION
This notice applies to the information and records we have
about your health,health status,and the health care and
services you receive at this office.Your health
information may include information created and received by
this office,may be in the form of written or electronic records
or spoken words,and may include information about your
health history,health status,symptoms,examinations,test
results,diagnoses,treatments,procedures,prescriptions,
related billing activity and similar types of health-related
information.

OW WE MAY USE AND DISCLOSE HEALTH
INFORMATION ABOUT YOU
We may use and disclose health information for the
following purposes:
For Treatment.We may use health information about you to
provide you with medical treatment or services.We may
disclose health information about you to doctors,nurses,
technicians,office staff or other personnel who are involved in
taking care of you and your health.For example,your doctor
may be treating you for a pregnancy and may need to know if
you have other health problems that could complicate your
care.The doctor may use your medical history to decide what
treatment is best for you.The doctor may also tell another
doctor about your condition so that doctor can help determine
the most appropriate care for you.
Different personnel in our office may share information about
you and disclose information to people who do not work in our
office in order to coordinate your care,such as phoning in
prescriptions to your pharmacy,scheduling lab work and
ordering x-rays,scheduling hospital procedures,or visits to
other offices.Nurses or staff may call you at home to discuss
your care;they may leave messages for you to call the office.
Family members and other health care providers may be part
of your medical care outside this office and may require
information about you that we have.
For Payment.We may use and disclose health information
about you so that the treatment and services you receive at
this office may be billed to,and payment may be collected
from you,an insurance company or a third party.
For example,we may need to give your health plan
information about a service you received here so your health
plan will pay us or reimburse you for the service.We may also
tell your health plan about a treatment you are going to
receive to obtain prior approval,or to determine whether your
plan will cover the treatment.
For Health Care Operations.We may use and disclose
health information about you in order to run the office and
make sure that you and our other patients receive quality
care.
For example,we may use your health information to evaluate
the performance of our staff in caring for you.We may also
use health information about all or many of our patients to
help us decide what additional services we should offer,how
we can become more efficient,or whether certain new
treatments are effective.
We may also disclose your health information to health plans
that provide you insurance coverage and other health care
providers that care for you.Our disclosures of your health
information to plans and other providers may be for the
purpose of helping these plans and providers provide or
improve care,reduce cost,coordinate and manage health
care and services,train staff,and comply with the law.
Appointment Reminders.We may contact you with a
reminder that you have an appointment for treatment or
medical care at the office.A message may be left on your
answering machine or voice mail.
Mailings.We may mail you appointment reminders or
notices about our practice.This correspondence may come
via post office or email.
Treatment Alternatives.We may tell you about or
recommend possible treatment options or alternatives that
may be of interest to you.
Health-Related Products and Services.We may tell you
about health-related products or services that may be of
interest to you.Please notify us if you do not wish to be
contacted for appointment reminders,or if you do not wish to
receive communications about treatment alternatives or
health related products and services.If you advise us in
writing (at the address listed at the top of this notice)that you
do not wish to receive such communications,we will not use
or disclose your information for these purposes.

SPECIAL SITUATIONS
We may use or disclose health information about
you without your permission for the following purposes,
subject to all applicable legal requirements and limitations:
To Avert a Serious Threat to Health or Safety.We may
use and disclose health information about you when
necessary to prevent a serious threat to your health and
safety or the health and safety of the public or another person.
Required by Law.We will disclose health information about
you when required to do so by federal,state or local law.
Research.We may use and disclose health information
about you for research projects that are subject to a special
approval process.We will ask you for your permission if the
researcher will have access to your name,address or other
information that reveals who you are,or will be involved in
your care at the office.
Organ and Tissue Donation.If you are an organ donor,we
may release health information to organizations that handle
organ procurement or organ,eye or tissue transplantation or
to an organ donation bank,as necessary,to facilitate such
donation and transplantation.
Military,Veterans,National Security and Intelligence.
If you are or were a member of the armed forces,or part of
the national security or intelligence communities,we may be
required by military command or other government authorities
to release health information about you.We may also release
information about foreign military personnel to the appropriate
foreign military authority.
Workers ’Compensation.We may release health
information about you for workers ’compensation or similar
programs,These programs provide benefits for work-related
injuries or illness.
Public Health Risks.We may disclose your health
information to public health authorities that are authorized by
law to receive and collect health information for the purpose
of preventing or controlling disease,injury or disability;to
report births,deaths,suspected abuse or neglect,reactions to
medications;or to facilitate product recalls.
Health Oversight Activities.We may disclose health
information to a health oversight agency for audits,
investigations,inspections,or licensing purposes.These
disclosures may be necessary for certain state and
federal agencies to monitor the health care system,
government programs,and compliance with civil rights laws.
Lawsuits and Disputes.If you are involved in a lawsuit or
a dispute,we may disclose health information about you in
response to a court or administrative order.Subject to all
applicable legal requirements,we may also disclose health
information about you in response to a subpoena.
Law Enforcement.We may release health information if
asked to do so by a law enforcement official in response to a
court order,subpoena,warrant,summons or similar process,
subject to all applicable legal requirements.
Coroners,Medical Examiners,and Funeral Directors.
We may release health information to a coroner or medical
examiner.This may be necessary,for example,to identify a
deceased person or determine the cause of death.
Information Not Personally Identifiable.We may use or
disclose health information about you in a way that does not
personally identify you or reveal who you are.
Family Pictures.It is our practice to display pictures that you
provide us with (for example,of your newborn baby)in our
facility.The name of the people in the photo may also be
displayed.If you are not in agreement to this,please refrain
from giving us photos.
Family and Friends.We may disclose information about
you to your family members or friends if we obtain your verbal
agreement to do so or if we give you an opportunity to object
to such a disclosure and you do not raise an objection.We
may also disclose health information to your family or friends
if we can infer from the circumstances,based on our
professional judgment that you would not object.For example,
we may assume you agree to our disclosure of your personal
health information to your spouse when you bring your spouse
with you into the exam room during treatment or while
treatment is discussed.
In situations where you are not capable of giving
consent (because you are not present or due to your
incapacity or medical emergency),we may,using our
professional judgment,determine that a disclosure to your
family member or friend is in your best interest.In that
situation,we will disclose only health information relevant to
the person ’s involvement in your care.For example,we may
inform the person who accompanied you to the hospital that
you are in labor or are being admitted for surgery and provide
updates on your progress and prognosis.We may also use
our professional judgment and experience to make
reasonable inferences that it is in your best interest to allow
another person to act on your behalf to pick up,for example,
filled prescriptions,medical supplies,or X-rays.

OTHER USES AND DISCLOSURES OF HEALTH
INFORMATION
We will not use or disclose your health information for any
purpose other than those identified in the previous sections
without your specific,written Authorization .If you give us
Authorization to use or disclose health information about you,
you may revoke that Authorization ,in writing ,at any time.If
you revoke your Authorization ,we will no longer use or
disclose information about you for the reasons covered by
your written Authorization ,but we cannot take back any uses
or disclosures already made with your permission.
In some instances,we may need specific,written
authorization from you in order to disclose certain types of
specially-protected information such as HIV,substance
abuse,mental health,and genetic testing information.

YOUR RIGHTS REGARDING HEALTH
INFORMATION ABOUT YOU
You have the following rights regarding health information we
maintain about you.
Right to Inspect and Copy. You have the right to inspect
and copy your health information, such as medical and billing
records, that we use to make decisions about your care. You
must submit a written request to our Privacy Officer in order
to inspect and/or copy your health information. If you request
a copy of the information, we may charge a fee for the cost of
copying, mailing or other associated supplies.
We may deny your request to inspect and/or copy in certain
limited circumstances. If you are denied copies of or access
to your health information, you may ask that the denial be
reviewed. If the law gives you a right to have our denial
reviewed, we will select a licensed health care professional to
review your request and our denial. The person conducting
the review will not be the person who denied your request,
and we will comply with the outcome of the review.
Right to Amend. If you believe health information we have
about you is incorrect or incomplete, you may ask us to
amend the information. You have the right to request an
amendment as long as the information is kept by this office.
To request an amendment, complete and submit a MEDICAL
RECORD AMENDMENT / CORRECTION FORM to our
Privacy Officer.
We may deny your request for an amendment if it is not in
writing or does not include a reason to support the request.
In addition, we may deny your request if you ask us to amend
information that:
•We did not create, unless the person or entity that
created the information is no longer available to make
the amendment
• Is not part of the health information that we keep
•You would not be permitted to inspect and copy
• Is accurate and complete
Right to an Accounting of Disclosures. You have the
right to request an “accounting of disclosures.” This is a list of
the disclosures we made of medical information about you for
purposes other than treatment, payment, health care
operations, and a limited number of special circumstances
involving national security, correctional institutions and law
enforcement. The list will also exclude any disclosures we
have made based on your written authorization.
To obtain this list, you must submit your request in writing to
our Privacy Officer. It must state a time period which may not
be longer than six years and may not include dates before
April 14, 2003. Your request should indicate in what form you
want the list (for example, on paper, electronically). The first
list you request within a 12-month period will be free. For
additional lists, we may charge you for the costs of providing
the list. We will notify you of the cost involved and you may
choose to withdraw or modify your request at that time before
any costs are incurred.
Right to Request Restrictions. You have the right to
request a restriction or limitation on the health information we
use or disclose about you for treatment, payment or health
care operations. You also have the right to request a limit on
the health information we disclose about you to someone who
is involved in your care or the payment for it, like a family
member or friend. For example, you could ask that we not use
or disclose information about a surgery you had.
We are not required to agree to your request. If we do
agree, we will comply with your request unless the information
is needed to provide you emergency treatment or we are
required by law to use or disclose the information.
To request restrictions, you may complete and submit the
REQUEST FOR RESTRICTION ON USE/DISCLOSURE OF
MEDICAL INFORMATION to our Privacy Officer.
Right to Request Confidential Communications. You
have the right to request that we communicate with you about
medical matters in a certain way or at a certain location. For
example, you can ask that we only contact you at work or by
mail.
To request confidential communications, you may complete
and submit the REQUEST FOR RESTRICTION ON
USE/DISCLOSURE OF MEDICAL INFORMATION AND/OR
CONFIDENTIAL COMMUNICATION to our Privacy Officer.
We will not ask you the reason for your request. We will
accommodate all reasonable requests. Your request must
specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice. If you have
received this notice electronically, you have the right to a
paper copy of this notice. You may ask us to give you a copy
of this notice at any time. Even if you have agreed to receive
it electronically, you are still entitled to a paper copy. To obtain
such a copy, contact our Privacy Officer.

CHANGES TO THIS NOTICE
We reserve the right to change this notice, and to make the
revised or changed notice effective for medical information we
already have about you as well as any information we receive
in the future. We will post a summary of the current notice in
the office with its effective date in the top right hand corner.
You are entitled to a copy of the notice currently in effect.