Notice of Privacy Practices

Effective April 14, 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.

In the process of providing medical care, The Doctors Clinic collects and retains personal information concerning our patients. The Doctors Clinic respects the privacy of your personal information and appreciates the importance of protecting this information by keeping it confidential and stored in a secure manner. The Doctors Clinics employees are committed to maintaining the privacy and confidentiality of your protected health information and wish to provide you with notice of our policies and procedures about privacy and confidentiality. This Notice describes how The Doctors Clinic has taken steps in accordance with Federal and State laws to protect the confidentiality of the protected health information you entrust to us. This Notice also describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations, and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. We are required to follow the terms of this Notice.

Protected Health Information

“Protected Health Information” (PHI) is information that identifies you and relates to your identity and your past, present or future medical history. It includes your medical records and personal information such as your name, social security number, address, and phone number.

How we may Use and Disclose Your Protected Health Information

For Treatment: Information obtained by our nurses, physicians, or other members of our health care team will be recorded in your medical record and used to help decide what care may be right for you. We may also share this information to facilitate referrals or transmit critical information to other treating physicians or specialists, nursing facilities, laboratories, radiology, or related facilities that provide care or perform diagnostic tests ordered by your physician. We may also share this information with agencies that provide services to you, such as pharmacies or apothecary shops.

For Payment: We may disclose information to health plans to confirm health care coverage or to receive payment for services provided by your physician. This information might be shared with hospitals, insurance carriers or Medicare to determine eligibility for insurance coverage. Information provided to health plans may include your diagnosis, procedures performed or recommended care.

For Health Care Operations: This information may be used in connection with training of our health care providers and staff. We may use your medical records to assess quality and improve services. We may contact you to remind you about appointments, obtain payment, provide test results, or give you information about treatment alternatives or other health-related benefits and services. We may use and disclose information to conduct or arrange for services, including: 1) Medical quality review by your health plan; 2) Accounting, legal, risk management, and insurance services; 3) Audit functions, including fraud and abuse detection and compliance programs.

Notification of Family and Others: Unless you object, we may release health information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may tell your family or friends your condition and that you are in a hospital. In addition, we may disclose information about you to assist in disaster relief efforts. You have the right to object to this use or disclosure of your information. If you object, we will not use or disclose it.

Uses and Disclosures of Personal Information that Do Not Require Patient Consent

State and federal laws allow The Doctors Clinic to disclose your protected health information without your consent in the following circumstances:

Medical Researchers: If the research has been approved and has policies to protect the privacy of your health information.

Funeral Directors/Coroners: Consistent with applicable laws to allow them to carry out their duties.

Food and Drug Administration: Relating to problems with food, supplements, and products.

Workers’ Compensation: To comply with laws if you make a Workers’ compensation claim.

Public Health and Safety: As allowed or required by law to prevent or reduce a serious, immediate threat to the health or safety of a person, or the public. To public health or legal authorities to prevent or control disease, injury, or disability. To report vital statistics such as births or deaths.

Correctional Institutions: If you are in jail or prison, your personal information will be disclosed, as necessary, for your health and the health and safety of others.

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.

Public Authorities: Child abuse, domestic violence, or neglect, may require that public health entities be notified.

Work-Related Conditions: Any conditions that could affect employee health may be disclosed. For example, an employer may ask us to assess health risks on a job site.

Military Authorities: The law may require us to provide information necessary to a military mission.

Specialized Government Functions: For example, we may share information for national security purposes.


Your Individual Rights

Access to Personal Information

The health information and billing records we create and store are the property of The Doctors Clinic. The protected health information in it, however, generally belongs to you. You have a right to review and copy your protected health information. If you wish to do so, you must notify The Doctors Clinic in writing. A mutually convenient time and place will be established, so that you may inspect your protected health information. You may have a copy of information if you wish, although in some circumstances access or reproduction may be denied if it is in violation of public law. You will be informed if there is an administrative fee for copying of this information.

Right to Amended Protected Health Information

State and federal law allows you the right to request an amendment. In some cases your request may be denied. If so, we will advise you of any denial and the reasons for such a denial. In some cases you may have the right to ask for a review of our denial.

Right to Receive an Accounting of Disclosures

You also have the right to request an accounting of all disclosures of your personal information made by The Doctors Clinic that are not directly related to your treatment, payment

for your treatment, or our health care operations as outlined above. You may request an accounting in writing. The Doctors Clinic will provide this information within a reasonable period of time.

Right to Receive This Notice

You have a right to request and receive a copy of this notice in written or electronic form. You may contact The Doctors Clinic for a copy, and one will be provided to you at no charge. You may also view this notice on our web site at this address: www.thedoctorsclinic.com

Right to Request Restriction on Disclosure of Personal Information

You may request restrictions of the use of your protected health information. All requests must be in writing. Upon receipt, The Doctors Clinic will review the request and notify you of its decision to either accept or reject the request. Please note that we are not required to agree to your request. If we do agree, we will honor your limits unless it is an emergency situation. All requests to restrict the use of protected health information must comply with state and federal law in order to be approved. All requests for restrictions which are agreed to will be made a permanent part of your medical record. If we choose to honor your request, we reserve the right to reverse our decision at a later date, after providing notice to you that we intend to do so.

Right to Confidential Communications

You have the right to request that your protected health information be provided to you in a confidential manner. We ask that this request be in writing. You may request that your protected health information be sent in writing, by telephone, or by fax, either to your home address or to a different address.

To Ask for Help or If You Have a Complaint

If you have a question about your rights, want more information, or want to report a problem about the handling of your protected health information, you may contact any clinic manager by calling (360) 782-3700 or deliver a written complaint to the Privacy Officer at:

The Doctors Clinic

Attn: Privacy Office

2512 Wheaton Way

Bremerton, WA 98310