NOTICE OF PRIVACY PRACTICES

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.

Who Is Subject to This Notice

 This Notice applies to Qliance Medical Group of Washington PC and its physicians, medical staff and patients.

Use and Disclosures of Health Information

We respect your privacy. We maintain administrative, physical, and technical safeguards to protect your health information. Your health information includes your symptoms, test results, diagnoses, treatments, health information from other providers, billing and payment information relating to these services, date of birth, Social Security Number, and other private information. The following categories describe different ways we use and disclose health information. Not every use or disclosure in a category will be listed.

Use and Disclosure of Your Health Information for Treatment, Payment, and Operations

Treatment: We may use and disclose your health information to give you care and to coordinate and manage your treatment or other services. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process.

Additionally, we receive laboratory results and imaging reports from outside laboratories and diagnostic facilities. We also may disclose your health information to other health care providers. For example, we may provide your health information to a surgeon who will be operating on you at a hospital.

Payment: We may use and disclose your health information to bill and collect payment from you or, as applicable, your employer, for services you received. For example, we may give information, such as that you are one of our patients, to your employer so your employer will pay your monthly care fees. We also may share your information with other providers who are involved in your care for their payment purposes. Some of the health information we collect includes financial information, including information contained in forms you complete and submit to obtain services (your Social Security Number, insurance number, credit information, etc.) and information relating to your transactions with us or others, such as your payment history and insurance and financial information.

Health Care Operations: We may use and disclose health information about you for our operations. For example, our quality improvement team may use your health information to assess the care and outcomes in your case and others like it. We may disclose your health information to other of your providers or to health plans for their own health care operations, on a limited basis, as allowed by law.

Appointment Reminders, Treatment Alternatives, and Health-Related Benefits and Services: We may use and disclose your health information to: remind you about appointments with us; tell you about alternative treatment therapies, providers, or settings of care; and tell you about health-related products, benefits, or services related to your treatment or care. We may send you newsletters about general health matters, our services, and wellness programs.

Disclosures and Uses of Health Information Unless You Object 

Unless you object, we may disclose health information about you to a friend or family member who is involved in your medical care or who helps pay for your care. In addition, we may disclose health information about you to assist in disaster relief efforts or for notification purposes. You have the right to object to this disclosure of your information. If you object, we will not disclose it.

Use and Disclose your Protected Health Information Without your Authorization 

We may use and disclose your health information without your authorization as follows: 

For public health and safety purposes as required by law to public health or legal authorities to protect public health and safety, to prevent or control disease, injury, or disability, and to report vital statistics such as births or deaths;

To report suspected abuse or neglect to public authorities; 

To prevent or reduce a serious, immediate threat to the health or safety of a person or the public; 

To the Food and Drug Administration relating to problems with food, supplements, and products; 

To organ procurement organizations or persons who obtain, store, or transplant organs, if you so direct; 

To comply with workers' compensation laws if you make a workers' compensation claim; 

For law enforcement purposes such as when we receive a subpoena, court order, or other legal process or you are the victim of a crime; 

For health and safety oversight activities. For example, we may share health information with the Department of Health; 

For disaster relief purposes such as to share health information with disaster relief agencies to assist in notification of family or others of your location or condition; 

For work-related conditions that could affect employee health. For example, an employer may ask us to assess health risks on a job site; 

To the military authorities of U.S. and foreign military personnel if you are connected to the military; 

In the course of judicial or administrative proceedings at your request or as directed by a subpoena or court order; 

With medical researchers if the research has been approved and has procedures to protect the privacy of your health information or, in limited circumstances, if needed in preparation for a research project; 

To funeral directors or coroners consistent with applicable law to allow them to carry out their duties; 

For specialized government functions, such as for national security purposes; 

To correctional institutions if you are in jail or prison, as necessary for your health and the health and safety of others; 

To personal representatives for minors and incapacitated adults; 

To our business associates who are contractually required to safeguard your protected health information; 

As incidental disclosures that may occur as a by-product of permitted uses and disclosures. For example, someone in the waiting room may hear your name called; and 

As de-identified information and limited data sets, in which certain identifiers (such as name and address) have been removed, making it unlikely that you could be identified, as allowed by law. 

Other Uses and Disclosures of Protected Health Information and Additional Information

Uses and disclosures not referenced in this Notice will be made only with your written authorization or as required by law. Certain of your health information may be subject to additional confidentiality protections. We provide patients the opportunity to communicate with us via electronic means (e-mail, fax, etc.). These communications are not encrypted. If you choose to communicate with us via e-mail, please note that we cannot ensure the confidentiality of the information contained in e-mail messages. Most employers have access to employee email content so if you use your work email, your employer may be able to read the messages sent to/from our office. 

Your Health Information Rights

The health and billing records we create and store are the property of our clinic. The health information in it, however, generally belongs to you. 

You have the following rights: 

Right to Inspect and Copy: You have the right to inspect and obtain copies of health information that we may use to make decisions about your care. We may deny your request in certain limited circumstances. To inspect or obtain a copy of your health information in our medical records, you must submit your request on our designated form to our Privacy Officer. We may charge you a reasonable fee for the costs of copying, mailing, or other supplies related to your request. 

Right to Amend: If you feel that health information we have about you is incorrect or incomplete, then you have the right to request a reasonable amendment for as long as we keep this information. We may deny your request in certain situations. To request an amendment, you must submit your request on our designated form to our Privacy Officer. 

Right to an Accounting of Disclosures: You have the right to request an accounting of certain disclosures of your health information made by us. This accounting will not include disclosures: for treatment, payment, or health care operations; to you under your right of access to your records; that you authorized; to persons involved in your care or for facility directory and notification purposes; incidental to an otherwise permitted use or disclosure; as part of a limited data set; for national security or intelligence purposes; to correctional institutions or other custodial law enforcement officials; or that occurred before April 14, 2003. To request an accounting, you must submit your request on our designated form to our Privacy Officer. 

Right to Request Restrictions: You have the right to request a restriction or limitation on the health information we use 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 your care. To request a restriction, you must submit your request on our designated form to our Privacy Officer. 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.

Right to Request Confidential Communications: You have the right to request that we communicate with you about health matters in a certain way or at a certain location. To request confidential communications, you must submit our designated form to our Privacy Officer.

Right to a Copy of this Notice: You have the right to receive a written copy of this Notice (even if you agreed to receive this Notice electronically). You may print a copy of this Notice from our website at qliance.com. You may call us and ask for a copy or stop by our reception desk. Our Responsibilities Regarding Your Health Information We are required by law to: maintain the privacy of your health information; give you this Notice of our legal duties and privacy practices with respect to the information we collect and maintain about you; and follow the terms of the Notice that is currently in effect. 

Changes To This Notice 

We reserve the right to change this Notice. The revised Notice will be effective for information we already have about you as well as any information we receive in the future. Unless otherwise required by law, the revised Notice will be effective on the new effective date of the Notice. The current Notice will be available in our registration areas or on our website and will be posted in our facilities. 

To Ask Questions or To Complain

If you have questions, want more information, or want to report a problem about the handling of your health information, you may communicate with our Privacy Officer at: 

Qliance Primary Care of Washington PC
Attn: Privacy Officer
509 Olive Way, Suite 1607
Seattle, WA 98101

Phone: 206-381-3030
Fax: 206-381-3035
Email:

You also may file a complaint with the U.S. Secretary of Health and Human Services. The Privacy Officer can give you information about filing a complaint. If you complain, we will not reduce your level of service because of it or retaliate against you.