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.

Proliance Surgeons, Inc., P.S. respects your privacy. We understand that your personal health information is very sensitive. We will not disclose your information to others unless you tell us to do so, or unless the law authorizes or requires us to do so.Laws protect the privacy of the health information we create and obtain in providing our care and services to you. For example, your protected health information includes your symptoms, test results, diagnoses, treatment plans, health information from other providers, and billing and payment information relating to these services. Federal and state law allows us to use and disclose your protected health information for purposes of treatment and health care operations. State law requires us to get your authorization to disclose this information for payment purposes.

Examples of Use and Disclosures of Protected Health Information for Treatment, Payment, and Health Operations

For treatment:

  • Information obtained by a nurse, physician, or other member 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 provide information to others providing you care. This will help them stay informed about your care.

For payment:

  • 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 diagnoses; procedures performed, or recommended care. NOTE – You may request that we not share information with your health plan provided that: (i) the disclosure is for purposes of payment or health care operations and is not otherwise required by law, and (ii) the health information pertains solely to health care items or services for which you, or another person on your behalf (other than a health plan) has paid in full.

For health care operations:

  • We use your medical records to assess quality and improve services.
  • We may use and disclose medical records to review the qualifications and performance of our health care providers and to train our staff.
  • We may contact you to remind you about appointments and give you information about treatment alternatives or other health-related benefits and services.
  • We may contact you during negotiations with your health insurance carrier or to inform you of changes with our relationship to your health insurance carrier.
  • Under certain circumstances, we may use and disclose your information for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another, for the same condition. Before we use or disclose your information for research, the project will go through a special approval process. Even without special approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, as long as they do not remove, take, or copy your information.
  • We may use or disclose your health information to provide legally required notices of unauthorized access to or disclosure of your health information.
  • We may use and disclose your information to conduct or arrange for services, including:
    • medical quality review by your health plan;
    • accounting, legal, risk management, and insurance services,and
    • audit functions, including fraud and abuse detection and compliance programs.

Your Health Information Rights

The health and billing records we create and store are the property of the practice/health care facility. The protected health information in it, however, generally belongs to you. You have a right to:
  •  Receive, read, and ask questions about this Notice.
  • Ask us to restrict certain uses and disclosures. You must deliver this request in writing to us. We are not required to grant the request, but we will comply with any request granted.
  • Request and receive from us a copy of this or the most current Notice of Privacy Practices for Protected Health Information (“Notice”).
  • Request that you be allowed to see and get a copy of your protected health information. You may make this request in writing. We have a form available for this type of request.
  • You have the right to request to be given or have transmitted to another individual or entity, an electronic copy of your medical record, if they are maintained in an electronic format. We will make every effort to provide the electronic copy in the format you request, however, if it is not readily producible by us, we will provide it in our standard format (fees my apply).
  • Have us review a denial of access to your health information—except in certain circumstances.
  • Ask us to change your health information. You may give us this request in writing. You may write a statement of disagreement if your request is denied. It will be stored in your medical record, and included with any release of your records.
  • When you request, we will give you a list of disclosures of your health information. The list will not include disclosures to third-party payors. You may receive this information without charge once every 12 months. We will notify you of the cost involved if you request this information more than once in 12 months.
  • Cancel prior authorizations to use or disclose health information by giving us a written revocation. Your revocation does not affect information that has already been released. It also does not affect any action taken before we have it. Sometimes, you cannot cancel an authorization if its purpose was to obtain insurance.
  • You have the right to request a restriction or limitation on the disclosure of your health information 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 involved in your care or involved in the payment of your care. Your request must be made in writing with specific instructions. If we agree to this restriction, we may violate the request only for emergency treatment. You may not request that we restrict the disclosure of your health information for treatment purposes.
For help with these rights during normal business hours, please contact the administrator of the location at which you have been treated. Please call the main office phone number and ask for the administrator.

Our Responsibilities

We are required to:
  • Keep your protected health information private;
  • Give you this Notice, and
  •  Follow the terms of this Notice and state and federal laws.

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 calling and asking for it or by visiting our office to pick one up.

Other Disclosures and Uses of Protected Health Information

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.You have the right to object to this use or disclosure of your information. If you object, we will not disclose it to your family member or friends.

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

With Medical Researchers—if the research has been approved and has policies to protect the privacy of your health information. We may also share information with medical researchers preparing to conduct a research project.
  • To Funeral Directors/Coroners consistent with applicable law to allow them to carry out their duties.
  • To Organ Procurement Organizations (tissue donation and transplant) or persons who obtain, store, or transplant organs.
  • To the Food and Drug Administration (FDA) relating to problems with food, supplements, and products.
  • To Comply With Workers’ Compensation Laws—if you make a workers’ compensation claim.
  • For Public Health and Safety Purposes 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, and
    • to public health or legal authorities;
    • to protect public health and safety
    • to prevent or control disease, injury, or disability
    • to report vital statistics such as births or deaths.
  • To Report Suspected Abuse or Neglect to public authorities.
  • To Correctional Institutions if you are in jail or prison, 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.
  • For Health and Safety Oversight Activities.For example, For example, we may share health information with the Department of Health.
  • For Disaster Relief Purposes. For example, we may share health information with disaster relief agencies to assist in notification of your condition to family or other.
  • 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. For example, the law may require us to provide information necessary to a military mission.
  • In the Course of Judicial/Administrative Proceedings at your request, or as directed by a subpoena or court order.
  • For Specialized Government Functions. For example, we may share information for national security purposes.

Other Uses and Disclosures of Protected Health Information

  • Uses and disclosures not in this Notice will be made only as allowed or required by law or with your written authorization.
  •  Uses and disclosure of psychotherapy notes or HIV status will only be made with your written authorization or as allowed by law.
  • Uses and disclosures of Protected Health Information for marketing purposes; and disclosures that constitute a sale of your Protected Health Information will be made only with your written authorization.

Electronic Health Record

  • To promote quality of care, we use an electronic health record that shares health information among many providers and that is owned and operated by Swedish Health Services, a Washington non-profit corporation. This computer system is used by many providers including those not affiliated with Proliance Surgeons. This electronic health record lets us and other providers look at and/or add information about you, your health, the care you receive, and other important facts. Not all your information is kept in the electronic health record. Not every provider that treats you looks at or adds information in the electronic health record. We cannot remove information once it is placed in the electronic health record.

For Additional Information, For Assistance or To Complain

  • We have a Web site that provides information about us. For your benefit, this Notice is on the Web site at this address:
  • If you have questions, want more information, or want to report a problem about the handling of
    your protected health information, please contact the administrator of the location at which you have been treated. If you believe your privacy rights have been violated, you may discuss your concerns with any staff member. You may also contact the administrator at any of our practice/health care facilities or Proliance Surgeon’s privacy office at (206)838-2590. You may also contact the U.S. Secretary of Health and Human Services. We respect your right to file a complaint with us or with the U.S. Secretary of Health and Human Services. If you complain, we will not retaliate against you. We reserve the right to change this notice and make the new notice apply to Health Information we already have as well as any information we receive in the future. We will post a copy of our current notice at our office. The notice will contain the effective date on the last page, in the lower left-hand corner.

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601 Broadway 7th Floor 
Seattle, WA 98122
3400 California Ave SW Ste. 210 
Seattle, WA 98116
(206) 386-2600

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601 Broadway 
7th Floor 
Seattle, WA 98122
(206) 386-2600

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