NOTICE OF PRIVACY PRACTICES
The Waldorf Center for Plastic Surgery, P.C.

Effective Date :March 2003

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.

For more information about this Notice, or to report a problem:
Please contact our Privacy Officer, Catherine A Zielinski, MHA at (503) 646-0101. 12400 NW Cornell Rd, Suite 200 Portland, OR 97229.

Kathleen A. Waldorf, M.D., P.C. ("Waldorf") is required by law to maintain the privacy of your medical information. Waldorf also is required to notify you of its legal duties and privacy practices regarding your medical information, and to abide by the practices described in this notice.

Waldorf may share your medical information with appropriate physicians, nurses, and other participants in the patient care system, such as affiliated clinics or hospitals, as necessary for your treatment and to monitor and improve the quality of care. We may also disclose medical information to health plans, claims processors, plan administrators, and insurers to obtain payment for services provided. Waldorf physicians may also disclose medical information to family or friends involved in your care, unless you object. Other uses require your specific authorization. The following describes how Waldorf may use and disclose your information without express permission. Other parts of this notice describe uses and disclosures that require your authorization, and the rights you have to restrict or to request restrictions on Waldorf’s use and disclosure of your medical information.

This section discusses the requirements of federal privacy laws. Oregon law provides additional protections in some circumstances.

• Treatment. We are permitted to use and disclose your medical information as necessary to provide you with medical treatment and services. For example, Waldorf physicians and other health professionals will document information about your treatment in your medical record. This record may be released to other health professionals to ensure that they are fully informed about your medical condition and treatment needs.
• Payment. We are permitted to use and disclose your medical information for our payment purposes or the payment purposes of other health care providers or health plans. For example, our billing department may release medical information to your health insurer to allow the insurer to pay us or reimburse you for your treatment.
• Health care operations. We are permitted to use and disclose your medical information for purposes of Waldorf’s healthcare operations. "Healthcare operations" are administrative, business, and managerial activities of Waldorf. For example, Waldorf may use your medical information to monitor the record-keeping practices of its physicians or nurses, or to ensure that Waldorf is complying with state and federal laws. We are also permitted to disclose your medical information to other health care providers or health plans for their healthcare operations concerning quality assurance, the qualifications of health care professionals or quality improvement programs. For example, the quality assurance department of a supplier of medical products may use your medical information to monitor or assess the quality of care in your case.

Oregon law: Oregon law provides additional privacy protections in some circumstances. For example, a health care provider in Oregon generally may not release the results of an HIV test without your consent and you must be notified of this right. Release of drug and alcohol treatment records also typically requires your specific consent under both federal and state law. Mental health records are subject to special protections in some circumstances, as is genetic information.

For more information on Oregon law related to these and other specially protected records, please contact the Privacy Officer. The Oregon Revised Statutes and the Oregon Administrative Rules that contain these laws are available on-line at www.oregon.gov.

• Fundraising. We may use demographic information about you to contact you in an effort to raise money for worthy causes. We only would release contact information, such as your name, address and phone number and when you received treatment. If you do not want your information used in this way, you must notify the privacy officer by a written opt out to be kept on file.
• Family or friends involved in your care. Waldorf physicians, using their best judgment, may disclose to a family member or close personal friend, or anyone else you identify, medical information relevant to that person’s involvement in your care. We also may give information to someone who helps pay for your care. If you do not want us to make these disclosures, you must notify the privacy officer by a written opt out to be kept on file.
• In the Event of a Disaster. We may disclose medical information about you to other health care providers and to an entity assisting in a disaster relief effort to coordinate care and so that your family can be notified about your condition and location. If you do not want us to make these disclosures, you must notify the privacy officer by a written opt out to be kept on file.
• Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care.
• Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that Waldorf offers that may be of interest to you.
• Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.

We may use or disclose your medical information for the following purposes:

• Research when approved by an Institutional Review Board (or Privacy Board). Under certain circumstances, Waldorf may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who underwent one procedure to those who underwent another, for the same condition. All research projects involving patients are subject to a special approval process through an Institutional Review or Privacy Board. Before Waldorf may use or disclose medical information for research purposes without your authorization, the project must be approved through this research approval process.
• To organ procurement organizations, for purposes of organ and tissue donation. If you are an organ donor, Waldorf may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
• To the military as required by military command authorities. If you are a member of the armed forces, Waldorf may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
• As authorized by law in connection with the Workers’ Compensation Program. We may release medical information about you for workers’ compensation or similar programs providing benefits for work-related injuries or illness, but only to the extent authorized by law.
• To support public health activities. Public health activities typically involve reports to agencies like the Oregon Department of Human Services as required or authorized by state law. These reports may be:

• To prevent or control disease, injury or disability;
• To report births and deaths;
• To report child abuse or neglect;
• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
• To notify the appropriate government authority of suspected abuse or neglect of an adult patient when required or authorized by law. We will promptly inform the patient of such a report if made.
• To notify the Food and Drug Administration of adverse events concerning food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

• To state and federal regulatory agencies. We may disclose medical information to state and federal agencies overseeing the healthcare industry, as authorized by law. These oversight activities include billing audits, investigations and inspections, and enforcement of licensure requirements. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
• Pursuant to lawful subpoena or court order. If you are involved in a lawsuit or a dispute, Waldorf may disclose medical information about you in response to a court or administrative order. We also may disclose medical information about you in response to a civil subpoena, discovery request, or other lawful process by someone involved in a civil lawsuit, but only if you are informed of the request or the party has attempted to obtain an order protecting the information requested.
• To law enforcement officials for certain law enforcement purposes. We may disclose your medical information to law enforcement officials as required by law or as directed by court order, warrant, criminal subpoena or other lawful process, and in other limited circumstances for purposes of identifying or locating suspects, fugitives, material witnesses, missing persons or crime victims.
• To coroners, medical examiners and funeral directors. We may release medical information to a coroner or medical examiner as necessary to identify a deceased person or to carry out their duties as required by law. Oregon law specifically requires us to report to the medical examiner an injury apparently resulting from a gunshot wound.
• For national security and intelligence activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
• When required to avert a serious threat to health or safety. We may use and disclose medical 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.
• Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President or foreign heads of state, or to conduct special investigations.
• Inmates. If you are an inmate of a correctional institution or in the custody of a law enforcement official, Waldorf may release medical information about you to the correctional institution or law enforcement official. Such release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
• As required by federal, state or local law. We may disclose medical information about you when required to do so by federal, state or local law.
• Incidental disclosures. Incidental disclosures of your medical information may occur as a byproduct of permitted uses and disclosures of your medical information. For example, a visitor may inadvertently overhear a discussion about your care at the checkout station. Waldorf must take reasonable measures to safeguard your medical information.
• Limited data set information. We may disclose limited health information to third parties for purposes of research, public health and certain health care operation purposes. This limited information includes only the following identifiers:

• Admission, discharge, and service dates;
• Dates of birth and, if applicable, death;
• Age (including age 90 or over); and
• Five-digit zip code or any other geographic subdivision, such as state, county, city, precinct and their equivalent geocodes (except street address).

Before disclosing this information, Waldorf must enter into an agreement with the recipient of the information that limits who may use or receive the data and requires the recipient to agree not to re-identify the data or contact you. The agreement must contain assurances that the recipient of the information will use appropriate safeguards to prevent inappropriate use or disclosure of the information.


Uses and disclosures requiring your authorization

Uses and disclosures of your personal health information for purposes other than described above require your express authorization. For example, Waldorf must obtain your authorization before disclosing your medical information to an employer, except under special circumstances such as when disclosure to the employer is required by law. You have the right to revoke an authorization at any time, except to the extent Waldorf has already relied on it in making an authorized use or disclosure. Your revocation of an authorization must be in writing.

If you choose to revoke an authorization, then we ask that you help us comply with your wishes by identifying the authorization in some way; e.g., by indicating who you authorized to receive information or the approximate time frame in which you signed the authorization.


Disclosures to Business Associates

Waldorf contracts with outside companies that provide services for and to us, such as billing companies, management consultants, quality assurance reviewers, accountants or attorneys. In certain circumstances, Waldorf may need to share your medical information with a business associate so it can perform a service on our behalf. Waldorf will limit the disclosure of your information to a business associate to the amount of information that is the minimally necessary to perform services for Waldorf. In addition, Waldorf will have a written contact in place with the business associate requiring it to protect the privacy of your medical information.

You have the right to:

• Inspect and copy medical information used to make decisions about your care. Usually, such information is contained in medical and billing records. To inspect and copy medical such information, you must submit a request in writing. If you request a copy of the information, Waldorf may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, then you may request that the denial be reviewed. Psychotherapy notes may not be inspected or copied.
• Request an amendment to your medical record. If you believe that medical information that may be used to make decisions about your care is incorrect or incomplete, then you may request that the information be amended or supplemented. This request must be in writing. Your request must include a reason for the amendment. We may deny your request if Waldorf believes the records are complete and accurate, if the records were not created by us and the creator of the record is available, or if the records are otherwise not subject to patient access. We will put denials in writing and explain our reasons for denial. You have the right to respond in writing to our explanation, and to require that your request, our denial, and your statement of disagreement, if any, be included in future disclosures of the disputed record.
• Request that Waldorf communicate by alternative means or at alternative locations. For example, you may ask that Waldorf only contact you at work or by mail. A request for alternative communication must be made in writing. We will honor all reasonable requests.
• Request restrictions on the use and disclosure of your medical record. You have the right to request restrictions on the medical information Waldorf uses or discloses about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information Waldorf discloses about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that Waldorf not disclose information about a particular procedure that you have undergone. Requests for such restrictions must be in writing. Waldorf may not agree to your request, but if Waldorf does agree, then Waldorf will comply with your request unless the information is needed to provide you with emergency treatment.
• Obtain an accounting of disclosures. You may obtain an accounting of disclosures Waldorf has made of your medical information in the previous six years, beginning April 14, 2003. Requests for an accounting must be in writing. You are not entitled to an accounting of disclosures made for purposes of treatment, payment or healthcare operations, disclosures you authorized, disclosures to you, incidental disclosures, disclosures to family or other persons involved in your care, disclosures to correctional institutions and law enforcement in some circumstances, disclosures to persons involved in your care, disclosures of limited data set information or disclosures for national security.
• Receive a paper copy of this notice if you received the notice electronically. You may obtain a paper copy of this notice at any time by requesting a copy from any member of our staff.

Please direct requests discussed above to the privacy officer at (503) 646-0101.

Waldorf reserves the right to change its practices and this notice. We reserve the right to change our health information practices and the terms of this notice, and to make the new provisions effective for all protected health information Waldorf maintains, including health information created or received prior to the effective date of any such revised notice. Should our health information practices change, Waldorf will post the revised notice at our office and make the revised notice available to you at your request.

If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer, or with the Secretary of the Department of Health and Human Services, 200 Independent Avenue S.W., Washington, DC. The DHHS toll-free telephone number is 1-877-696-6775. There will be no retaliation for filing a complaint.