Effective Date: September 23, 2013

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:

Therapeutic Associates Inc.
Attn: Privacy Officer
16083 SW Upper Boones Ferry Rd, Suite 300,
Tigard, OR 97224
503.443.6156 / 800.219.8835

Email – [email protected]


This notice describes the procedures and practices that this clinic and its professional, support, and administrative staff follow to protect the privacy of your health information.

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, it may be in the form of written or electronic records or spoken words, and it 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 maintain the privacy of your health information and to give you this notice. It will tell you about the ways in which we may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of that information. We are required to abide by the terms of this notice, and to notify you of a breach of your unsecured health information.

How 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, the doctor who referred you for physical therapy may be treating you for a medical or orthopedic condition, and we may need to know about that and any other health problems that could complicate your treatment. We may use your medical history to decide what treatment is best for you. We will consult with your doctor and send reports about your treatment to the doctor. We do this to provide 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 telephoning your doctor and getting needed information. Family members and other health care providers may be part of your physical therapy outside this office and that may require us to provide information about you.

For Payment: We may need to use or disclose health information about you in order to obtain payment for our health care services. For example, we may bill your health plan, insurance company, or other third party for your treatment in this clinic. We may also need to tell your health plan or insurance company about a treatment you are going to receive in order to obtain prior approval, or to determine whether your plan will pay for the treatment.

For Health Care Operations: We may use and disclose health information about you in order to manage the clinic and ensure 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 treatments are effective for certain problems.

We may also disclose your health information to your health plan and other health care providers that care for you in order to help these plans and providers evaluate or improve care, reduce cost, coordinate and manage health care and services, train staff, and comply with the law.

Other circumstances

We may use or disclose health information about you for the following purposes, in accordance with the requirements and limitations of state and other law:

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 or under certain other limited circumstances.

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 health information about you for public health reasons in order to prevent or control disease, injury, or disability; or report suspected abuse or neglect, non-accidental physical injuries, or problems with products.

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: We may disclose your health information in response to a court or administrative order, subpoena, discovery request, or other legal process, subject to certain restrictions.

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. We may release health information to funeral directors as necessary for them to carry out their duties.

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 and Friends: We may disclose health information about you to your family members, friends, or others involved in your care or payment 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 room during treatment or while treatment is discussed.

In situations where you are not capable of giving consent (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.

Personal Representative: If you have a personal representative who has authority to make health care decisions on your behalf, such as a parent or guardian, we may disclose your health information to such a personal guardian.

Other uses and disclosures pursuant to your signed authorization

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. We will not sell your health information, use or disclose any psychotherapy notes about you, or use or disclose your health information for marketing purposes without your Authorization unless otherwise permitted under federal law. If you sign an Authorization for us 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.

Your rights regarding your health information

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 our Privacy Officer (at the address listed at the top of this Notice) in order 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 may deny your request to inspect and/or copy records 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 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 Correct: 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 a correction as long as the information is kept by this office.

To request a correction, complete and submit a MEDICAL RECORD AMENDMENT/CORRECTION FORM to our Privacy Officer. We will provide you with one of these forms at your request.

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 your request if you ask us to correct information that:

  • We did not create, unless the person or entity that created the information is no longer available to make the correction
  • 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 record 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 record may also exclude any disclosures we have made based on your written authorization.

To obtain this accounting, you must submit your request in writing to our Privacy Officer. It must state the time period for which you want an accounting. The time period may not be longer than six years. 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.

If you or someone on your behalf pays for a service in full and you request that we not disclose information about the service to your health plan for purposes of payment of health care operations, we are required to agree to your request unless the disclosure is required by law. For all other types of restriction requests, 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 AND/OR CONFIDENTIAL COMMUNICATION to our Privacy Officer. We will provide you with one of these forms at your request.

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 or e-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: 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 the 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 the current notice or 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.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact our Privacy Officer (at the address listed at the top of this Notice). You will not be penalized for filing a complaint.