This notice describes how medical information about you may be used and disclosed and how you can obtain access to this information.
Please review it carefully.
Our pledge and obligations regarding your health care information here at Colonial Clinic. We are required by State and Federal law maintain the privacy of protected health information, give you this notice of our legal duties and privacy practices regarding health information about you.
Colonial Clinic must follow the privacy practices as described below. This notice will remain in effect until it is amended or revised by Colonial Clinic.
Colonial Clinic will keep your health information confidential, using it only for the following purposes listed below; Except for the purposes described below, we will use and disclose Health Information only with your written permission. You may revoke such permission at any time.
• Treatment: Colonial Clinic may use your health information to provide you with professional services that span across our organization. Breakthrough has an established infrastructure that limits employee access to your health information according to their primary job functions. Every employee or affiliated service provider is required to sign a confidentiality agreement.
• Payment: will use and disclose your protected health information to obtain payment for services provided to you. Colonial Clinic may share information with your insurance company or other businesses that may become involved in the process of mailing statements and/or collecting unpaid balances.
• Healthcare or Family / Friend Disclosure: Colonial Clinic may disclose your health information with other health care professionals who provide treatment and/or services to you. These professionals will have a privacy and confidentiality policy like this one and whom agree to follow all state and federal regulations regarding confidentiality. Health information about you may also be disclosed to your family, friends, and/or other persons you choose to involve in your care, only if you agree and sign a release of authorization form that is specific to the nature of the information being disclosed.
• Business Operations Disclosure: Colonial Clinic may use or disclose your protected health information, in regard to the care provided to you, for the purpose of education and training, legal requirements, and accounting or payment matters. Colonial Clinic may share information with other entities that provide assistance in your care and whom agree to follow all state and federal regulations regarding confidentiality.
• Appointment Reminders: Colonial Clinic may use or disclose your health information to provide you with appointment reminders, including, but not limited to, voicemail messages, secure EMR messages notification applications, postcards, or letters.
• Marketing Health-Related Services: Colonial Clinic will not use your health information for marketing purposes unless you have provided written authorization to do so.
• Required by Law: The law provides that Colonial Clinic may use or disclose your protected health information in certain situations, including:
• In an emergency or for disaster relief purposes, such as to notify family about your whereabouts and condition;
• To report abuse or neglect (See Informed Consent form for detailed information regarding Colonial Clinic ’s duty to disclose abuse or neglect);
• To persons authorized by law to act on your behalf, such as a guardian, health care power of attorney or surrogate;
• Where required by U.S. Department of Health and Human Services to determine our compliance;
• To assist law enforcement in the event of a possible crime on the premises. Colonial Clinic may also share your information to prevent or lessen a serious or imminent threat to you or another person.
• When requested by national security, intelligence, and other state and federal officials and/or if you are an inmate or otherwise under the custody of law enforcement.
• By order of a court, subpoena or applicable legal discovery request.
Other uses and disclosures will be made only with your written authorization. If you sign an authorization, you may revoke it at any time, except to the extent that we have already shared your information based upon your permission.
Your Privacy Rights with respect to your protected health information as an individual enrolled in care with Colonial Clinic:
You have the right to inspect and copy your protected health information, with the exception of copying of the evaluation. This usually includes medical and/or billing records. You must submit a request to Colonial Clinic in writing and agree to be responsible for a fee before a copy will be provided. Copies, if requested, will be $0.25 per page. It will take a maximum of 10 business days from the date of the written request and receipt of fee to fulfill any records request. If Colonial Clinic is unable to provide you with the records in the format you request, Colonial Clinic will provide records in a form that works for you and our office. You may also ask us to transmit your record to a specific person or entity via email if,
a) you provide the email address in writing and,
b) sign a statement that you fully understand that email comes with inherent risks that we cannot prevent and for which Colonial Clinic is not responsible. Under certain circumstances, your provider may not allow you to see certain parts of your record. You may ask that this decision be reviewed by another licensed professional.
Colonial Clinic does not give out a printed copy of the full assessment to the individual clients. You have the right to request a review of the assessment and all supporting documentation with either the assessing counselor or with the Administrator if you have any questions in regards to diagnosis or treatment placement.
With properly signed release of information we will send the full assessment to another treatment facility if you are attending services there or seeking a second opinion. Treatment providers are subject to strict confidentiality laws and cannot give printed release of 3rd party information that is received; we are able to review with you as a part of your records.
You have the right to ask Colonial Clinic to contact you in a manner and/or place that you believe will keep your information private, for example, to contact you at a different address or telephone number.
You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose all or part of your protected health information for the purpose of treatment, payment, or healthcare operations. Colonial Clinic will consider your request carefully and may honor reasonable requests where possible. Colonial Clinic is not required to honor all requests. You may also ask that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must identify the specific restriction requested and to whom you want the restriction to apply.
You have the right to receive an accounting of disclosures in which Colonial Clinic has made of your protected health information. This essentially means you may receive a listing of certain uses or disclosures made for other than treatment, payment or business operations, and which you have not received or authorized, such as where Colonial Clinic was required to share information for a public health purpose.
You may ask Colonial Clinic to amend your record. While Colonial Clinic employees cannot erase your record, a written statement can be added to your protected health information to correct or clarify the record. Your provider may submit a response to the new correction, which will be provided to you.
Breach Notification. If there is a breach in your health information, Colonial Clinic will notify you, government officials, and others, as the law requires.
Questions and Complaints:
You have the right to file a complaint with Colonial Clinic if you feel there has been a violation of Privacy Practices. Your complaint should be directed to Colonial Clinic Administrator. If you feel there has been a violation of your privacy rights, or if you disagree with a decision made regarding your access to your health information, you can direct this to the Administrator as well.
Colonial Clinic supports your right to the privacy of your information and will not retaliate in any way if you choose to file a complaint with the facility or with the Washington State Department of Health. Contact information can be found below.
Huston Stolz, Administrator
910 N Washington St, Ste 210
Spokane, WA 99201
Department of Health
Health System Quality Assurance/Complaint Intake
PO Box 47857
Olympia, WA 98504
Toll Free: 800-633-6828