Notice of Privacy Practices

NOTICE OF PRIVACY PRACTICES
Effective Date: April 1^st, 2025
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: The Sellwood Medical Clinic at 503-595-9300 The Sellwood Medical Clinic 8332 SE 13th Avenue Portland, Oregon 97202

Who Will Follow This Notice:

This notice describes the information privacy practices followed by our employees, staff, and other personnel.

Your Information: This notice applies to the protected information and records we have about you, your health, and the health care and services you receive from The Sellwood Medical Clinic. Your information may include information created and received by The Sellwood Medical Clinic, 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.

We are required by law to give you this notice. It will tell you about the ways in which we may use and disclose information about you and describes your rights and our obligations regarding the use and disclosure of that information.

How We May Use and Disclose Information About You:

We may use and disclose health information for the following purposes:

For Treatment: We may use information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, nurses, technicians, staff, or other personnel who participate in taking care of you and your health.

For example, your doctor may be treating you for a heart condition and may need to know if you have other health problems that could complicate your treatment. 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 the doctor can help determine the most appropriate care for you.

Different personnel in our organization may share information about you and disclose information to people who do not work for The Sellwood Medical Clinic to coordinate your care, such as phoning in prescriptions to your pharmacy, scheduling lab work and ordering x-rays. 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. We will request your permission before sharing health information with your family or friends unless you are unable to give permission to such disclosures due to your condition or status.

For Payment: We may use and disclose information about you so that the treatment and services you receive at The Sellwood Medical Clinic 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 pay for the treatment.

For Health Care Operations: We may use and disclose information about you in order to run The Sellwood Medical Clinic and make sure that you and our other patients receive quality care.

For example, we may use your information to evaluate the performance of our staff in caring for you. We may also use information about 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 information to health plans that provide your 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.

Fundraising: We may contact you to ask for your help with different fundraising campaigns. Please notify us if you do not wish to be contacted during fund-raising campaigns. 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 information about you 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 information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or others.
Required By Law: We will disclose information about you when required to do so by federal, state, or local law.
Research: We may use and disclose 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 information to organizations that manage 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, military command or other government authorities may require us to release information about you. We may also release information about foreign military personnel to the appropriate foreign military authority.
Workers’ Compensation: We may release information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.
Public Health Risks: We may disclose information about you for public health reasons in order to prevent or control disease, injury, or disability; or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.
Health Oversight Activities: We may disclose 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 participate in a lawsuit or a dispute, we may disclose 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 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 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 information about you in a way that does not personally identify you or reveal who you are.
Family and Friends: We may disclose information about you to your family members or friends if we obtain your verbal or written 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 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 protected health information to your spouse when you bring your spouse with you into the exam room or the hospital 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 only disclose information relevant to the person’s involvement in your care. For example, we may inform the person who accompanied you to the emergency room that you suffered a heart attack 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

We will not use or disclose your information for any purpose other than those identified in the previous sections without your specific, written, or verbal authorization. If you give us authorization to use or disclose 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 substance abuse, mental/behavioral health, or reproductive health information for purposes such as treatment, payment, and healthcare operations.

Prohibited Disclosures

In compliance with the HIPAA Privacy Rule: Final Rule to Support Reproductive Health Care Privacy, The Sellwood Medical Clinic will not use or disclose your protected health information for either of the following activities:

To conduct a criminal, civil, or administrative investigation into or impose criminal, civil, or administrative liability on any person for the mere act of seeking, obtaining, providing, or facilitating reproductive health care, where such health care is lawful under the circumstances in which it is provided.
The identification of any person for the purpose of conducting such investigation or imposing such liability. Under the Final Rule, the prohibition applies where The Sellwood Medical Clinic (a covered entity) has reasonably determined that one or more of the following conditions exists:
The reproductive health care is lawful under the law of the state in which such health care is provided under the circumstances in which it is provided. For example, if a resident of one state traveled to another state to receive reproductive health care, such as an abortion, that is lawful in the state where such health care was provided.
The reproductive health care is protected, required, or authorized by Federal law, including the U.S. Constitution, regardless of the state in which such health care is provided. For example, if use of reproductive health care, such as contraception, is protected by the Constitution.
The reproductive health care was provided by a person other than the covered health care provider, health plan, or health care clearinghouse (or business associates) that receives the request for PHI and the presumption described below applies.

The Final Rule continues to permit covered entities (such as The Sellwood Medical Clinic) to use or disclose PHI for purposes otherwise permitted under the Privacy Rule where the request for the use or disclosure of PHI is not made to investigate or impose liability on any person for the mere act of seeking, obtaining, providing, or facilitating reproductive health care.

For example: A covered health care provider could continue to use or disclose PHI to defend themselves in an investigation or proceeding related to professional misconduct or negligence where the alleged professional misconduct or negligence involved the provision of reproductive health care.

A covered health care provider, health plan, or health care clearinghouse (or business associates) could continue to use or disclose PHI to defend any person in a criminal, civil, or administrative proceeding where liability could be imposed on that person for providing reproductive health care.

A covered health care provider, health plan, or clearinghouse (or their business associates) could continue to use or disclose PHI to an Inspector General where the PHI is sought to conduct an audit for health oversight purposes.

Attestation

If/when we receive a request for PHI potentially related to reproductive health care, we will obtain a signed attestation confirming that the use or disclosure is not for a prohibited purpose. This attestation requirement applied when the request for PHI is for any of the following:

Health oversight activities
Judicial and administrative proceedings
Law enforcement purposes
Disclosures to coroners and medical examiners

Your Rights

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 keep and use to make decisions about your care. You must submit a written request to the Sellwood Clinic Leadership Team to inspect and/or copy records of your health information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other associated supplies. 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. A modified request may include requesting a summary of your medical record. If you request to view a copy of your information, we will not charge you for inspecting your health information. If you wish to inspect your health information, please submit your request in writing to the Sellwood Clinic Leadership Team. You have the right to request a copy of your health information in electronic form if we store your health information electronically.

We may deny your request to inspect and/or copy your record, or parts of your record, in certain limited circumstances. If you are denied copies of or access to health information that we keep about you, you may ask that our 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 subsequent 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 the 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 The Sellwood Medical Clinic.

To request an amendment, submit a request via email to mrecords@sellwoodmd.com to the Sellwood Medical Clinic. We may deny your request for an amendment if your request is not in writing or does not include a reason to support the request. In addition, we may deny or partially 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.

If we deny or partially deny your request for an amendment, you have the right to submit a rebuttal, and request that the rebuttal be made as part of your medical record. Your rebuttal needs to be (2) pages or less in length, and we have the right to file a rebuttal responding to your rebuttal in your medical record. You also have the right to request that all documents associated with the amendment request (including rebuttal(s)) be transmitted to any other party any time the associated portion of the medical record is disclosed.

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, or health care operations, when specifically authorized by you and a limited number of special circumstances involving national security, correctional institutions, and law enforcement. To obtain this list, you must submit your request in writing to the Sellwood Medical Clinic Leadership Team. The request must state a time period, which may be no longer than six years. Your request should indicate in what form you want the list (for example: paper or electronic). 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 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 information we disclose about you to someone who participates in your care or the payment for it, such as a family member or friend.

For example, you may 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 with emergency treatment, or we are required by law to use or disclose the information.

We are required to agree to your request if you pay for treatment, services, supplies, and/or prescriptions “out of pocket” and you request that the information not be communicated to your health plan for the purpose of payment or health care operations. There may be instances where we are required to release this information if required by law.

To request restrictions, you may complete and submit the Request for Restriction on the Use/Disclosure of Medical Information to The Sellwood Medical Clinic Leadership Team.

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 may ask that we only contact you at work or by mail. To request confidential communications, you may complete and submit the Request for Confidential Communication to Sellwood Medical Clinic Leadership Team. 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: You have the right to receive 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 the notice electronically, you are still entitled to a paper copy. (You can also find a copy of this Notice on our website at www.sellwoodmd.com. To obtain a hard copy, please contact The Sellwood Medical Clinic Leadership Team.

Changes to This Notice:

We reserve the right to revise this notice, and to make the revised notice effective for information we already have about you, as well as any information we receive in the future. We will post the current notice at our location(s) with its effective date in the top right-hand corner. You are entitled to a copy of the notice currently in effect. We will inform you of any significant changes to this notice. This may be communicated through our newsletter, a sign prominently posted at our location(s), a notice posted on our website, or other means of communication.

Breach of Health Information: We will inform you if there is a breach of your health information.

Complaints: If you believe your rights have been violated, you may file a complaint with our office, or with the Secretary of the Department of Health and Human Services at: Office for Civil Rights Region X U.S. Department of Health & Human Services 2201 Sixth Avenue - M/S: RX-11 Seattle, WA 98121-1831 Voice Phone (800) 368-1019 FAX (206) 615-2297 TDD (800) 537-7697 To file a complaint with Sellwood Medical Clinic, or for more information about this notice, contact the Sellwood Medical Clinic Leadership Team at 503-595-9300. You will not be penalized for filing a complaint.

Discrimination is Against the Law:
The Sellwood Medical Clinic complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Sellwood Medical Clinic does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Sellwood Medical Clinic provides free aids and services to people with disabilities, or people whose primary language is not English, to allow them to communicate effectively with us. This includes qualified interpreters and written information available in other languages or formats.

If you believe that Sellwood Medical Clinic has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

The Sellwood Medical Clinic at: Sellwood Medical Clinic Attn: Clinic Leadership 8332 SE 13th Ave. Portland, OR 97202 Phone: (503) 595-9300 Fax: (503)-595-9301 Email: mrecords@sellwoodmd.com You may file a grievance in person, by mail, or by email. If you need assistance filing a grievance, the Sellwood Medical Clinic Leadership Team is available to help you.

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