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.
Fourth Corner Neurosurgical respects your privacy. We understand that your personal health information is very sensitive. The law protects the privacy of the health information we create and obtain in providing care and services to you. Your protected health information includes your symptoms, test results, diagnoses, treatment, and health information from other providers, billing and payment information relating to these services.
We will not use or disclose your health information to others without your authorization, except as described in this Notice, or as required by law.
The health and billing records we create and store are the property of Fourth Corner Neurosurgical. The protected health information in it, however, generally belongs to you. You have a right to:
For help with these rights during normal business hours, please contact:
Medical Records Department
It is the responsibility of Fourth Corner Neurosurgical
Keep your protected health information private.
Give you this Notice.
Follow the terms of this Notice.
We have the right to change our practices regarding the protected health information we maintain. If we make changes, we will update this Notice. You may receive the most recent copy of this Notice by contacting our and medical records department, or visiting our office.
If you have questions, want more information, or want to report a problem about the handling of your protected health information, you may contact us at 360-676-0922
If you believe your privacy rights have been violated, you may discuss your concerns with any staff member at Fourth Corner Neurosurgical. You may also file a complaint with the Department of Health and Human Services Office for Civil Rights (OCR).
We respect your right to file a complaint with us or with the OCR. If you complain, we will not retaliate against you.
Under the law, we may use or disclose your protected health information under certain circumstances without your permission. The following categories describe the different ways we may use and disclose your protected health information. For each category, we will explain what we mean and give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose health information will fall within one of the categories.
Information obtained by a nurse, physician, or other member of our health care team will be recorded in your medical record and used by members of our health care team to help decide what care may be right for you.
We may also provide information to health care providers outside our practice who are providing you care or for a referral. This will help them stay informed about your care.
We request payment from your health insurance plan. Health plans need information from us about your medical care. Information provided to health plans may include your diagnosis; procedures performed, or recommended care.
We bill you or the person you tell us is responsible for paying for your care if it is not covered by your health insurance plan.
For health care operations:
We may contact you to remind you about appointments.
We may use and disclose your health information to give you information about treatment alternatives or other health-related benefits and services.
Required by law: We must make any disclosure required by state, federal, or local law.
Business Associates: We contract with individuals and entities to perform jobs for us or to provide certain types of services that may require them to create, maintain, use, and/or disclose your health information. We may disclose your health information to a business associate, but only after they agree in writing to safeguard your health information. Examples include billing services, accountants, and others who perform health care operations for us.
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.
Public health and safety purposes:
Research: We may disclose protected health information to researchers if the research has been approved by an institutional review board or a privacy board and there are policies to protect the privacy of your health information. We may also share information with medical researchers preparing to conduct a research project.
Coroners, medical examiners, and funeral directors: We may disclose protected health information to funeral directors and coroners consistent with applicable law to allow them to carry out their duties.
Organ-procurement organizations: Consistent with applicable law, we may disclose protected health information to organ-procurement organizations (tissue donation and transplant) or persons who obtain, store, or transplant organs.
Food and Drug Administration (FDA): For problems with food, supplements, and products, we may disclose protected health information to the FDA or entities subject to the jurisdiction of the FDA.
Workplace injury or illness: Washington State law requires the disclosure of protected health information to the Department of Labor and Industries, the employer, and the payer (including a self-insured payer) for workers’ compensation and for crime victims’ claims. We also may disclose protected health information for work-related conditions that could affect employee health; for example, an employer may ask us to assess health risks on a job site.
Correctional institutions: If you are in jail or prison, we may disclose your protected health information as necessary for your health and the health and safety of others.
Law enforcement: We may disclose protected health information to law enforcement officials as required by law, such as reports of certain types of injuries or victims of a crime, or when we receive a warrant, subpoena, court order, or other legal process.
Government health and safety oversight activities: We may disclose protected health information to an oversight agency that may be conducting an investigation. For example, we may share health information with the Department of Health.
Disaster relief: We may share protected health information with disaster relief agencies to assist in notification of your condition to family or others.
Military, Veteran, and Department of State: We may disclose protected health information to the military authorities of U.S. and foreign military personnel; for example, the law may require us to provide information necessary to a military mission.
Lawsuits and disputes: We are permitted to disclose protected health information in the course of judicial/administrative proceedings at your request, or as directed by a subpoena or court order.
National Security: We are permitted to release protected health information to federal officials for national security purposes authorized by law.
De-identifying information: We may use your protected health information by removing any information that could be used to identify you.
We have a Web site that provides information about us. For your benefit, this Notice is on the Web site at the following address: fourthcornerneurosurgical.com
Effective date: July 11, 2012
Fourth Corner Neurosurgical Associates INC PS complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Fourth Corner Neurosurgical Associates INC PS does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Fourth Corner Neurosurgical Associates INC PS, Provides free aids and services to people with disabilities to communicate effectively with us, such as:
If you need these services, contact our front desk staff or appointment scheduler.
If you believe that Fourth Corner Neurosurgical Associates INC PS has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
Amy Smith, 710 Birchwood Ave #101, Bellingham, WA 98225
Telephone: 360-676-0922, Fax: 360-671-4726, or e-mail: email@example.com
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the
Office for Civil Rights Complaint Portal, available at:
or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.