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.

Our Pledge to Protect Your Privacy

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at our facility. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated at Northwest Behavioral Healthcare Services (NBHS), whether made by our employees or other practitioners involved in your care.

This notice will tell you about the ways in which we may use and disclose medical information about your child. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to make sure that medical information that identifies you is kept private; give you this notice of our legal duties and privacy practices with respect to medical information about you; and follow the terms of the notice that is currently in effect.

If you have any questions about this notice, please contact our Privacy Officer at (503)722-4470 ext.221.

Who Will Follow This Notice

The following individuals and organizations share NBHS? commitment to protect your privacy and will comply with this Notice: Any health care professional authorized to enter information into your medical records at our facility. Members of our medical staff, employees, business associates, volunteers, trainees, students, and other facility personnel who might provide services in our facility.

Note: This facility may provide services to you in an integrated way with our medical staff and the affiliated patient care settings referenced above. However, NBHS accepts no legal responsible for activities solely attributable to these other providers or care settings.

Members of our medical staff, appropriate facility employees and other participants in our patient care system, such as affiliated laboratories or pharmacies, may share your medical information as necessary for your treatment, payment for services provided and health care operations, without your express permission. Other uses require your specific authorization. The following describes how we 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 our use and disclosure of your medical information.

Uses and disclosures without your express permission

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 within this facility and with our affiliated service providers as necessary to provide you with medical treatment and services. For example, your doctor will tell the nurse what medications you need to take, how much and how often. The nurse practitioner might need to communicate any physical limitations to those who coordinate recreation activities. Physicians and other health professionals treating you in this facility will document information about your treatment in your medical record. This record will be released to other health professionals assisting in your treatment to ensure 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 our own facility operations. We also are permitted to disclose your medical information for the health care operations of another health care provider or health plan so long as they have a relationship with you and need the information for their own quality assurance purposes, for purposes of reviewing the qualifications of their health care professionals or conducting skill improvement programs. For example, our quality assurance department may use your medical information to assess the quality of care in your case and ensure our facility continues to provide the quality care you and other patients deserve. We may use your medical information to ensure we are complying with all federal and state compliance requirements.

Oregon law: Oregon law provides additional confidentiality protections in some circumstances. For example in Oregon, a health care provider generally may not release the identity of a person tested for HIV or the results of an HIV-related test without your consent, and you must be notified of this confidentiality right. Drug and alcohol records are specially protected and typically require your specific consent for release under both federal and state law. Mental health records are specially protected in some circumstances, as is genetic information. For more information on Oregon law related to these and other specially protected records, please contact our Privacy officer, or refer to the Oregon Revised Statutes and the Oregon Administrative Rules. These documents are available on-line at www.oregon.gov.

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.

Uses and disclosures that do not require your authorization

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

To organ procurement organizations, for purposes of organ and tissue donation. If you are an organ donor, we 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 support public health activities. These activities typically include reports to such agencies as the Oregon Department of Human Services as required or authorized by state law. These reports may include, but not necessarily be limited to, the following: 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 if we believe a patient has been the victim of abuse or neglect. We will only make this disclosure if the patient agrees or when required or authorized by law. To the Food and Drug Administration relative to adverse events concerning food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

To health oversight agencies such as state and federal regulatory agencies. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. 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, we may disclose medical information about you in response to a court or administrative order.

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.

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 in carrying out their duties as required 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.

As required by federal, state or local law. We will disclose medical information about you when required to do so by federal, state or local law.

Incidental disclosures. Certain incidental disclosures of your medical information occur as a byproduct of lawful and permitted use and disclosure of your medical information. For example, a visitor may inadvertently overhear a discussion about your care occurring at the nurses? station. These incidental disclosures are permitted if the facility applies reasonable safeguards to protect your medical information.

Limited data set information. We may disclose limited health information to third parties for purposes of research, public health and health care operation purposes. This health information includes only the following identifiers: Admission, discharge, and service dates; Dates of birth and, if applicable, death; Age; and Five-digit zip code or any other geographic subdivision, such as state, county, city, precinct and their equivalent geocodes (except street addresses).

Before disclosing this information, we 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.

Other uses and disclosures for purposes other than described above require your express authorization. For example, this facility must obtain your authorization before disclosing your medical information to a life insurer or 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 we have already relied on it in making an authorized use or disclosure. Your revocation of an authorization can be oral but is preferred in writing. Northwest Behavioral Healthcare Services hopes that if you choose to revoke an authorization, you will help us comply with your wishes by identifying the authorization you are choosing to revoke. Ways of telling us which authorization you are revoking might include indicating who you authorized to receive information or the approximate time frame in which you signed the authorization.

Disclosures to Business Associates

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

You have the right to:

Request to inspect and copy your medical information used to make decisions about your care. You have the right to inspect and copy medical information that may be used to make decisions about your care. To inspect and copy medical information that may be used to make decisions about patients, you must submit a request in writing. If you request a copy of the information, we 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, you may request that the denial be reviewed.

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, you may ask us to amend the information. This request must be in writing. Your request must include a reason for the amendment. We may deny your request if we believe 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 any denial in writing and explain our reasons for denial. You have the right to respond in writing to our explanation of denial, 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 we send you confidential communications by alternative means or at alternative locations. For example, you may ask that we only contact you at work or by mail. A request for confidential communication must be made in writing. We will honor all reasonable requests.

Request additional restrictions on the use and disclosure of your medical record. You have the right to request a restriction or limitation on the medical 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 medical information we disclose 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 we not use or disclose information about a particular procedure you underwent. To request a restriction, you must put your request in writing. We are not required to agree to your request for restrictions. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

Request an accounting of disclosures. Beginning April 14, 2003, you may request, in writing, an accounting of disclosures we made of your medical information in the previous six years. 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 of limited data set information or disclosures for national security or law enforcement purposes.

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.

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 we maintain, including health information created or received prior to the effective date of any such revised notice. Should our health information practices change, we will post the revised Notice at our service delivery sites 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 our Privacy Officer, or with the Secretary of the Department of Health and Human Services, 200 Independent Avenue S.W., Washington, D.C. The DHHS toll-free telephone number is 1-877-696-6775. There will be no retaliation for filing a complaint.